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🔍 Diagnosing Performance Anxiety: Key Considerations for Psych NP Students · Pearls and Prep

0:00
Foreign.
0:03
Welcome,
0:04
my
0:04
friends
0:05
to
0:05
Pearls
0:06
and
0:06
prep
0:07
your
0:07
go
0:07
to
0:07
spot
0:08
for
0:08
pearls
0:08
that
0:09
prep
0:09
you
0:09
for
0:09
practice.
0:10
Let's
0:11
dive
0:11
right
0:11
into
0:12
today's
0:12
mock
0:13
psychiatric
0:14
case
0:14
study.
0:15
Meet
0:16
Carly.
0:17
Carly
0:18
is
0:19
coming
0:19
to
0:19
you
0:20
in
0:20
the
0:20
outpatient
0:21
clinic
0:21
because
0:22
in
0:22
about
0:23
a
0:23
week
0:24
she's
0:24
going
0:24
to
0:25
have
0:25
to
0:25
give
0:25
a
0:25
eulogy
0:27
for
0:27
her
0:27
co
0:28
worker,
0:28
Gary.
0:29
Now,
0:30
Gary
0:30
tragically
0:31
passed
0:31
away
0:32
about
0:33
a
0:33
week
0:33
ago.
0:33
They
0:34
were
0:34
at
0:34
a
0:34
holiday
0:35
potluck
0:35
and
0:36
Gary
0:36
choked
0:37
on
0:37
a
0:37
piece
0:38
of
0:38
peanut
0:38
brittle.
0:39
He
0:39
died
0:40
right
0:40
then
0:40
and
0:40
there.
0:41
Carly
0:41
performed
0:42
the
0:42
Heimlich
0:42
maneuver,
0:43
but
0:43
she
0:43
could
0:44
not
0:44
revive
0:44
him.
0:44
It's
0:45
a
0:45
really
0:45
tragic
0:46
situation.
0:46
She's
0:47
coming
0:47
to
0:47
you
0:47
because
0:48
she
0:48
is
0:50
very
0:50
afraid
0:51
of
0:51
public
0:52
speaking
0:53
and
0:54
she
0:54
wants
0:54
you
0:54
to
0:55
help
0:55
figure
0:55
out
0:55
her
0:56
anxiety
0:57
and
0:57
what
0:57
she's
0:57
going
0:58
to
0:58
do
0:58
here.
0:58
She's
0:59
obviously
0:59
distraught.
1:00
She
1:00
lost
1:00
a
1:01
co
1:01
worker
1:01
and
1:02
she
1:02
tried
1:02
to
1:02
revive
1:03
him.
1:03
Her
1:04
CPR
1:04
certification
1:05
had
1:05
expired,
1:05
so
1:06
she
1:06
couldn't
1:06
do
1:07
chest
1:07
compressions,
1:07
which
1:08
made
1:08
her
1:08
feel
1:08
even
1:08
guiltier.
1:09
She's
1:09
coming
1:09
to
1:09
you
1:10
in
1:10
the.
1:10
In
1:10
the
1:10
context
1:11
of
1:11
performance
1:13
anxiety,
1:13
giving
1:14
the
1:14
eulogy
1:14
is
1:15
really
1:15
why
1:15
she's
1:16
here.
1:16
The
1:16
nervousness
1:17
behind
1:17
that.
1:18
Carly
1:18
experiences
1:19
severe
1:19
anxiety
1:20
and
1:20
panic
1:20
when
1:21
it
1:21
comes
1:21
to
1:21
public
1:21
speech
1:22
speaking.
1:22
Even
1:22
though
1:23
she's
1:23
pretty
1:23
good
1:23
in
1:24
other
1:24
social
1:24
situations,
1:25
she's
1:26
worried
1:26
she's
1:26
going
1:26
to
1:27
cry
1:27
or
1:27
stammer
1:28
or
1:28
freeze
1:28
during
1:28
the
1:29
eulogy
1:29
in
1:29
front
1:29
of
1:29
her
1:30
whole
1:31
library
1:31
of
1:32
co
1:32
workers.
1:32
It's
1:33
pretty
1:33
terrifying.
1:34
It's
1:34
a
1:34
pretty
1:34
loaded
1:35
situation
1:35
and
1:36
she's
1:36
pretty
1:36
distraught
1:37
in
1:37
your
1:37
office.
1:38
Her
1:38
exact
1:39
words
1:39
for
1:39
her
1:40
chief
1:40
complaint
1:40
are,
1:40
I'm
1:41
going
1:41
to
1:41
lose
1:42
my
1:42
mind
1:43
if
1:43
I
1:43
have
1:44
to
1:44
give
1:44
this
1:44
eulogy.
1:45
So
1:46
she
1:46
really
1:46
doesn't
1:46
want
1:46
to
1:47
do
1:47
this.
1:47
Now,
1:48
let's
1:48
go
1:48
right
1:48
into
1:49
chart
1:50
start
1:50
and
1:50
meet
1:51
Carly
1:51
more
1:51
officially
1:52
in
1:52
her
1:52
chart.
1:53
I
1:53
want
1:53
to
1:53
just
1:54
say
1:54
right
1:55
off
1:55
the
1:55
bat,
1:55
I'll
1:55
state
1:56
the
1:56
obvious.
1:57
This
1:57
is
1:57
Carly's
1:58
fake,
1:58
okay?
1:59
And
1:59
I
1:59
don't
1:59
mean
1:59
her
2:00
personality
2:00
is
2:00
fake,
2:01
that
2:01
she's
2:02
a
2:02
fake
2:02
person
2:02
that
2:02
you
2:02
don't
2:03
like
2:03
to
2:03
be
2:03
around.
2:03
I
2:03
mean
2:04
that
2:04
this
2:04
is
2:04
a
2:04
fake
2:04
patient.
2:05
There's
2:05
not
2:06
a
2:06
person
2:06
named
2:07
Carly
2:07
that
2:07
I've
2:07
seen.
2:08
This
2:08
is
2:08
a
2:08
mock
2:09
patient,
2:10
completely
2:11
made
2:11
up,
2:11
but
2:11
with
2:12
real
2:12
world
2:13
scenarios
2:13
that
2:13
you
2:14
actually
2:14
see
2:14
in
2:14
practice.
2:15
Gary,
2:16
too
2:16
is
2:16
a
2:16
made
2:16
up
2:17
person.
2:17
Has
2:18
there
2:18
ever
2:18
been
2:18
a
2:19
person
2:19
named
2:19
Gary
2:19
who
2:20
choked
2:20
on
2:20
peanut
2:20
brittle
2:21
at
2:21
a
2:21
holiday
2:22
potluck?
2:23
If
2:23
there
2:23
is,
2:23
sue
2:24
me.
2:24
We
2:25
are
2:26
moving
2:27
along
2:27
here
2:27
with
2:27
a
2:28
mock
2:28
psychiatric
2:29
case
2:30
study.
2:30
Now,
2:30
Carly
2:31
is
2:31
33
2:32
years
2:32
old
2:33
and
2:34
like
2:34
I
2:34
said,
2:35
she
2:35
is
2:36
very
2:36
nervous
2:37
in
2:37
front
2:37
of
2:37
people.
2:38
She's
2:38
going
2:38
to
2:39
have
2:39
a
2:39
meltdown,
2:39
if
2:40
you
2:40
will.
2:41
She
2:41
says
2:41
that
2:41
in
2:41
the
2:42
Past
2:42
she's
2:42
had
2:42
tremors,
2:43
sweaty
2:43
palms,
2:43
racing
2:44
heart,
2:44
dry
2:44
mouth.
2:45
Her
2:45
voice
2:45
can
2:46
often
2:46
crack
2:46
when
2:46
she's
2:47
in
2:47
performance
2:47
type
2:48
events.
2:49
All
2:49
of
2:49
that
2:49
is
2:50
really
2:50
not
2:50
fun.
2:51
Now
2:52
she
2:53
is
2:53
telling
2:53
you
2:54
that
2:54
she's
2:54
not
2:54
worried
2:55
in
2:55
general.
2:56
She
2:56
denies
2:57
any
2:57
panic
2:57
attacks
2:58
or
2:58
history
2:59
of
2:59
depressive
3:00
symptoms.
3:01
But
3:01
she
3:01
avoids
3:02
public
3:02
speaking,
3:03
being
3:03
in
3:03
front
3:03
of
3:03
crowds.
3:04
She
3:04
doesn't
3:04
like
3:04
the
3:04
limelight
3:05
at
3:05
all
3:06
because
3:06
of
3:06
these
3:07
physical
3:07
symptoms
3:07
that
3:08
are
3:08
really
3:08
embarrassing.
3:08
Another
3:09
few
3:09
other
3:10
things
3:10
about
3:10
Carla
3:10
you
3:11
should
3:11
know.
3:11
She,
3:12
in
3:12
terms
3:12
of
3:13
past
3:13
psychiatric
3:13
history,
3:14
did
3:14
receive
3:15
counseling
3:15
as
3:15
a
3:15
teen
3:16
when
3:16
her
3:16
mom
3:16
found
3:16
her
3:17
with
3:17
a
3:17
pack
3:17
of
3:17
cigarettes
3:18
in
3:18
her
3:18
pocket.
3:18
Her
3:19
trauma
3:19
history
3:19
is
3:20
positive
3:20
for
3:20
some
3:21
emotional
3:21
neglect.
3:21
But
3:22
beyond
3:22
that,
3:22
she
3:22
has
3:22
never
3:23
been
3:23
hospitalized
3:23
psychiatrically.
3:24
She's
3:25
never
3:25
been
3:25
on
3:25
psychiatric
3:26
medications
3:26
before,
3:27
hasn't
3:28
really
3:28
been
3:28
informal
3:29
therapy
3:29
of
3:29
any
3:30
kind.
3:30
She
3:31
does
3:31
not
3:31
drink
3:31
alcohol,
3:32
does
3:32
not
3:32
smoke,
3:33
doesn't
3:33
do
3:33
any
3:33
illegal
3:34
drugs.
3:35
She
3:35
did
3:35
take
3:35
MDMA
3:36
in
3:36
college
3:36
once
3:36
during
3:37
a
3:37
thrash
3:38
metal
3:38
rave.
3:40
But
3:40
beyond
3:40
that
3:41
isolated
3:41
incident,
3:42
she
3:42
does
3:42
not
3:42
do
3:43
any
3:43
kind
3:43
of
3:43
psychedelics.
3:44
Now
3:44
she
3:44
does
3:45
report
3:45
a
3:45
high
3:46
daily
3:46
caffeine
3:47
intake.
3:47
She
3:48
has
3:48
one
3:48
cup
3:48
of
3:49
death
3:49
wish
3:49
coffee
3:50
every
3:50
time
3:50
she
3:50
wakes
3:51
up.
3:51
So
3:51
keep
3:51
that
3:51
in
3:52
mind.
3:52
Now
3:53
she
3:53
lives
3:53
alone.
3:53
She
3:54
is
3:54
a
3:54
librarian,
3:55
as
3:55
we
3:55
discussed.
3:55
She's
3:56
pretty
3:56
high
3:56
functioning,
3:57
actually
3:58
socially
3:58
engaged.
3:59
She
3:59
does
3:59
have
3:59
a
3:59
group
4:00
of
4:00
friends
4:00
she
4:00
hangs
4:00
out
4:01
with.
4:01
They
4:01
go
4:01
to
4:01
Applebee's
4:02
on
4:02
Sundays
4:03
together
4:03
and
4:04
really
4:04
enjoy
4:04
their
4:05
time.
4:05
She's
4:06
been
4:06
divorced
4:06
twice.
4:06
She
4:07
grew
4:07
up
4:07
in
4:07
Arkansas.
4:08
Her
4:08
medical
4:09
history
4:09
is
4:09
unremarkable.
4:10
No
4:10
asthma,
4:10
no
4:11
cardiac
4:11
issues,
4:12
no
4:12
major
4:13
medical
4:13
problems
4:14
that
4:14
we're
4:14
aware
4:14
of.
4:15
Clean
4:15
bill
4:15
of
4:15
health
4:16
and
4:16
and
4:17
good
4:17
labs
4:18
twice
4:18
a
4:18
year
4:18
she
4:18
goes
4:19
to
4:19
her
4:19
primary
4:19
care
4:20
doctor.
4:20
Now
4:20
she
4:20
does
4:21
have
4:21
a
4:21
maternal
4:22
history
4:22
of
4:22
anxiety.
4:23
Her
4:23
mother
4:24
had
4:24
struggled
4:24
with
4:24
anxiety
4:25
throughout
4:25
her
4:25
life.
4:26
We're
4:26
not
4:26
sure
4:26
if
4:26
she's
4:26
ever
4:27
been
4:27
medicated.
4:27
Carly's
4:28
not
4:28
sure.
4:29
No
4:29
history
4:29
of
4:30
bipolar,
4:31
schizophrenia
4:31
or
4:31
any
4:31
other
4:32
family
4:32
diagnoses.
4:33
And
4:34
again,
4:34
she's
4:34
here
4:34
today
4:35
because
4:35
she
4:35
wants
4:35
some
4:35
short
4:36
term
4:36
relief
4:36
for
4:36
her
4:37
upcoming
4:37
eulogy.
4:38
This
4:38
is
4:38
really
4:39
consuming
4:39
her.
4:40
Now
4:40
let's
4:41
go
4:41
right
4:41
into
4:43
Q
4:44
tips.
4:45
Q
4:45
tips
4:46
is
4:46
a
4:46
section
4:47
where
4:47
we
4:48
ask
4:48
the
4:48
best
4:49
questions.
4:49
So
4:49
you
4:50
have
4:50
this
4:50
patient,
4:50
you
4:50
have
4:51
a
4:51
background,
4:51
you
4:51
have
4:51
a
4:51
chief
4:52
complaint,
4:52
right?
4:53
What
4:53
we've
4:53
got
4:54
to
4:54
do
4:54
now
4:54
is
4:54
figure
4:55
out
4:55
the
4:55
most
4:55
high
4:56
yield
4:56
questions
4:57
to
4:57
really
4:57
get
4:58
to
4:58
the
4:58
bottom
4:59
of
4:59
what
4:59
we
4:59
are
5:00
looking
5:00
at
5:00
here.
5:00
That's
5:01
the
5:01
key,
5:01
right?
5:02
Asking
5:02
great
5:03
questions
5:03
is
5:04
the
5:04
key
5:04
to
5:04
being
5:05
a
5:05
good
5:05
clinician.
5:06
Because
5:06
you
5:06
only
5:06
have
5:08
X
5:08
number
5:08
of
5:09
minutes
5:09
with
5:09
this
5:10
patient,
5:10
the
5:10
quality
5:11
of
5:11
your
5:11
questions
5:12
can
5:13
make
5:13
or
5:13
break
5:14
your
5:14
ability
5:14
to
5:15
get
5:15
the
5:15
diagnosis
5:16
right.
5:16
And
5:16
Subsequently,
5:17
the
5:17
treatment
5:18
you
5:18
choose.
5:19
So
5:19
every
5:19
time
5:19
you
5:19
see
5:20
a
5:20
patient,
5:20
be
5:21
mindful
5:22
that
5:23
you
5:23
live
5:23
and
5:23
die
5:25
by
5:25
virtue
5:26
of
5:26
the
5:26
questions
5:28
that
5:28
you
5:28
ask.
5:28
Now,
5:29
I'm
5:29
not
5:29
going
5:29
to
5:29
pretend
5:29
that
5:29
I'm
5:30
going
5:30
to
5:30
ask
5:30
every
5:30
great
5:31
question
5:31
out
5:31
there.
5:32
Psychiatry
5:32
is
5:33
both
5:33
an
5:33
art
5:33
and
5:33
a
5:33
science.
5:34
There
5:34
are
5:34
standard
5:35
questions
5:35
we
5:35
can
5:36
ask
5:36
and
5:36
we
5:36
can
5:36
sound
5:36
like
5:37
robots
5:37
all
5:37
day.
5:38
There's
5:38
a
5:38
time
5:38
and
5:38
place
5:39
for
5:39
those
5:39
too.
5:39
But
5:40
there's
5:40
also
5:40
an
5:41
art
5:41
to
5:41
asking
5:42
high
5:42
yield
5:43
questions
5:44
that
5:44
enable
5:45
you
5:45
to
5:45
build
5:45
rapport
5:46
with
5:46
your
5:46
patient.
5:47
That's
5:47
the
5:47
key.
5:47
If
5:47
you
5:48
do
5:48
sound
5:48
like
5:48
a
5:48
robot
5:49
and
5:49
a
5:49
checklist,
5:50
they're
5:50
going
5:50
to
5:50
think
5:50
to
5:50
themselves,
5:51
why
5:51
didn't
5:51
I
5:51
just
5:51
Google
5:52
this?
5:52
Why
5:52
didn't
5:53
I
5:53
just
5:53
take
5:53
a
5:53
few
5:54
checklists
5:55
online
5:55
to
5:56
figure
5:56
out
5:56
what's
5:56
wrong
5:56
with
5:57
me?
5:57
They
5:57
want
5:57
a
5:58
human.
5:58
We
5:58
are
5:59
a
5:59
social
5:59
species
6:00
and
6:00
they
6:00
depend
6:01
on
6:01
warm,
6:02
intelligent
6:03
questioning
6:03
that
6:03
gets
6:04
them
6:04
to
6:04
think
6:04
and
6:04
gets
6:05
you
6:05
to
6:05
the
6:05
right
6:06
diagnosis
6:07
so
6:07
you
6:07
can
6:07
get
6:08
the
6:08
right
6:08
treatment.
6:09
Those
6:09
are
6:09
extremely
6:10
important
6:11
elements
6:11
of
6:12
the
6:12
process.
6:12
Some
6:13
of
6:13
the
6:13
questions
6:13
that
6:13
I
6:14
would
6:14
ask
6:14
Carly,
6:15
off
6:15
the
6:15
bat,
6:16
it
6:16
are
6:16
in
6:16
general,
6:17
what
6:17
makes
6:17
you
6:17
anxious,
6:18
right?
6:19
You
6:19
can
6:19
get
6:19
so
6:19
much
6:20
information
6:21
out
6:21
of
6:21
the
6:21
answer,
6:22
depending
6:23
on
6:23
what
6:23
Carly
6:23
says.
6:24
Because
6:24
if
6:24
Carly
6:24
is
6:25
anxious
6:25
about
6:26
presentations
6:27
and
6:27
presentations
6:28
alone,
6:28
she's
6:29
going
6:29
to
6:29
tell
6:29
you
6:29
that
6:29
what
6:29
makes
6:30
me
6:30
anxious
6:30
is
6:31
I
6:31
can't
6:31
stand
6:32
being
6:32
in
6:32
the
6:32
limelight.
6:33
I
6:33
hate
6:33
giving
6:34
work
6:34
presentations.
6:35
I
6:35
can't
6:36
stand
6:36
giving
6:37
eulogies.
6:38
I'm
6:38
not
6:38
the
6:38
woman
6:39
to
6:39
ask
6:39
at
6:39
the
6:40
family
6:40
reunion
6:40
to
6:40
give
6:41
the
6:41
toast,
6:41
I'll
6:41
shrivel
6:42
up
6:43
and
6:43
jump
6:43
into
6:43
the
6:43
river
6:44
if
6:44
it's
6:44
me
6:45
who
6:45
has
6:45
to
6:45
give
6:45
that
6:46
toast,
6:46
I
6:46
will
6:46
hide
6:46
in
6:47
the
6:47
bathroom
6:47
and
6:48
scream
6:48
if
6:49
you
6:49
pick
6:49
me.
6:50
So
6:50
she's
6:51
going
6:51
to
6:51
tell
6:51
you
6:51
in
6:51
general
6:51
what
6:52
makes
6:52
you
6:52
anxious.
6:53
Now,
6:53
if
6:53
someone
6:54
has
6:54
more
6:54
of
6:54
a
6:55
generalized
6:55
anxiety
6:56
disorder,
6:56
you
6:56
might
6:57
get
6:57
a
6:57
whole
6:57
different
6:57
answer,
6:58
right?
6:58
You
6:58
might
6:59
get,
6:59
oh
6:59
my
6:59
God,
6:59
I
7:00
worry
7:00
about
7:00
everything.
7:01
How
7:01
many
7:01
times
7:01
I've
7:02
had
7:02
a
7:02
patient
7:02
who
7:02
tells
7:02
me
7:03
everything.
7:03
I
7:03
worry
7:03
about
7:04
everything.
7:04
I
7:04
worry
7:05
that
7:06
my
7:07
family's
7:07
going
7:07
to
7:07
get
7:08
into
7:08
a
7:08
car
7:08
accident.
7:08
I
7:09
worry
7:09
that
7:09
my
7:09
husband's
7:10
going
7:10
to
7:10
lose
7:10
his
7:10
job,
7:10
that
7:11
I'm
7:11
going
7:11
to
7:11
lose
7:11
my
7:11
job,
7:12
that
7:12
the
7:12
kids
7:13
are
7:13
going
7:13
to
7:13
get
7:13
malaria.
7:14
Right?
7:14
The
7:14
general
7:15
worry
7:15
about
7:15
everything
7:16
that
7:16
could
7:16
possibly
7:17
go
7:17
wrong.
7:17
The
7:18
worst
7:18
case
7:18
scenario
7:19
of
7:19
everything,
7:20
that's
7:20
more
7:20
of
7:21
a
7:21
generalized
7:21
anxiety
7:22
answer,
7:23
right?
7:23
Hence
7:24
the
7:24
word
7:24
general.
7:25
You're
7:25
going
7:25
to
7:25
get
7:25
a
7:26
wide
7:26
variety
7:26
of
7:27
really
7:27
catastrophic
7:28
worst
7:28
case
7:28
scenarios.
7:29
One
7:29
of
7:29
my
7:29
favorite
7:30
ways
7:30
to
7:30
look
7:31
at
7:31
this
7:31
came
7:31
from
7:31
a
7:32
patient
7:32
years
7:32
ago
7:33
that
7:33
basically
7:34
said
7:34
they
7:34
think
7:35
out
7:35
of
7:35
fear.
7:36
I
7:36
loved
7:36
that
7:37
brilliant
7:37
characterization
7:38
where
7:38
all
7:38
of
7:38
Their
7:38
thoughts
7:39
were
7:39
put
7:39
through
7:39
a
7:40
filter
7:40
of
7:40
fear.
7:41
Imagine
7:41
you
7:42
put
7:42
filters
7:42
on
7:43
photos
7:43
all
7:44
the
7:44
time,
7:44
right?
7:44
Now
7:45
imagine
7:45
the
7:45
generalized
7:46
anxiety
7:47
worrier
7:48
has
7:48
this
7:48
fear
7:49
filter.
7:50
Imagine
7:50
how
7:50
disabling
7:51
that
7:51
is,
7:51
right?
7:51
Everything
7:52
that
7:52
could
7:52
otherwise
7:52
be
7:53
pleasant
7:53
and
7:53
exciting
7:54
and
7:54
enjoyable
7:55
gets
7:55
put
7:55
through
7:55
a
7:56
filter
7:56
of
7:56
fear.
7:56
Now,
7:56
Carly
7:57
does
7:57
not
7:57
seem
7:58
to
7:58
be
7:58
giving
7:58
us
7:59
the
7:59
generalized
7:59
anxiety
8:00
vibes.
8:00
She
8:01
is
8:01
telling
8:01
you
8:02
that
8:03
her
8:03
anxiety
8:04
is
8:04
circumscribed
8:05
to
8:05
giving
8:05
speeches
8:06
or
8:06
being
8:07
in
8:07
the
8:07
limelight.
8:08
And
8:08
so
8:08
you
8:08
asked
8:08
her
8:09
that.
8:09
Let's
8:09
say
8:09
she
8:09
said,
8:10
okay,
8:10
I'm
8:11
only
8:11
worried
8:11
about
8:12
speeches.
8:12
Sometimes
8:12
you
8:13
don't
8:13
have
8:13
a
8:13
patient
8:13
who
8:13
is
8:14
as
8:14
generous
8:15
and
8:15
narrow
8:15
as
8:16
that,
8:16
but
8:17
then
8:17
you
8:17
can
8:17
broaden
8:17
out
8:18
and
8:18
say,
8:18
do
8:18
you
8:18
worry
8:18
about
8:19
everyday
8:19
things
8:19
like
8:20
finances,
8:20
health
8:21
or
8:21
family,
8:22
even
8:22
when
8:22
you're
8:22
not
8:22
in
8:23
a
8:23
social
8:23
situation?
8:24
So
8:24
that's
8:24
another
8:25
what
8:25
I
8:25
call
8:25
on
8:25
this
8:26
podcast,
8:26
Q
8:26
Tip.
8:27
Q
8:27
Tips
8:27
are
8:28
tips
8:28
about
8:29
which
8:29
questions
8:30
to
8:30
ask.
8:30
High
8:30
yield
8:31
questions.
8:32
Now,
8:33
with
8:34
Carly,
8:35
there
8:35
are
8:35
other
8:35
things
8:36
you
8:36
can
8:36
do
8:36
to
8:37
figure
8:37
this
8:37
out.
8:37
You
8:37
can
8:38
say,
8:38
when
8:38
you
8:38
feel
8:38
anxious
8:39
in
8:39
social
8:39
situations,
8:40
are
8:40
you
8:40
primarily
8:41
worried
8:41
about
8:41
being
8:41
judged
8:42
or
8:42
embarrassed
8:42
or
8:43
about
8:43
having
8:43
a
8:44
panic
8:44
attack
8:44
and
8:44
not
8:45
being
8:45
able
8:45
to
8:45
escape?
8:46
Is
8:46
this
8:46
really
8:46
about
8:46
the
8:47
social
8:47
situation
8:47
or
8:48
is
8:48
this
8:48
about
8:48
the
8:49
internal
8:49
bodily
8:49
sensations
8:50
that
8:51
bother
8:51
you,
8:52
that
8:52
create
8:53
alarm
8:53
bells
8:53
in
8:54
you,
8:54
that
8:54
make
8:54
you
8:55
want
8:55
to
8:55
run
8:55
away?
8:55
Because
8:56
those
8:56
are
8:56
two
8:56
different
8:56
things.
8:57
Right?
8:57
Again,
8:57
at
8:57
the
8:58
core,
8:58
at
8:59
the
8:59
core,
8:59
here
8:59
are
8:59
we
9:00
looking
9:00
at
9:02
anxiety
9:03
about
9:03
performance
9:04
in
9:04
front
9:04
of
9:04
others
9:05
or
9:05
about
9:06
symptoms
9:06
that
9:06
make
9:07
you
9:07
uncomfortable
9:08
that
9:09
you
9:09
want
9:09
to
9:09
run
9:09
away
9:09
from
9:10
and
9:10
escape
9:10
out
9:11
of?
9:11
Right.
9:11
One
9:12
is
9:12
more
9:12
panic
9:12
attack
9:13
related.
9:13
One
9:13
is
9:14
more
9:14
circumscribed
9:15
to
9:15
social
9:15
situations,
9:16
performance
9:17
related
9:18
in
9:18
nature.
9:20
Now
9:21
I
9:21
would
9:22
also
9:22
want
9:22
to
9:22
ask
9:22
Carly
9:23
what
9:23
other
9:24
social
9:24
situations
9:25
tend
9:25
to
9:25
provoke
9:26
the
9:26
most
9:26
anxiety.
9:27
Someone
9:28
who
9:28
is
9:29
performance
9:29
only,
9:30
who
9:30
really
9:30
only
9:31
gets
9:31
flustered,
9:32
overwhelmed
9:33
and
9:33
panicky
9:34
in
9:34
performance
9:34
situations,
9:35
they
9:35
might
9:36
say,
9:36
hey,
9:36
look,
9:37
I'm
9:37
actually
9:37
really
9:38
good.
9:38
Carly
9:39
said
9:39
she
9:39
went
9:39
to
9:39
Applebee's.
9:40
So
9:40
she
9:41
goes
9:41
to
9:41
Applebee's.
9:41
She's
9:42
able
9:42
to
9:42
have
9:42
a
9:42
group
9:43
of
9:43
friends.
9:43
She
9:43
wants
9:44
to
9:44
socialize.
9:44
She
9:45
socializes
9:45
decently.
9:46
She
9:46
tells
9:46
you
9:46
as
9:47
a
9:47
librarian,
9:48
she
9:48
gets
9:48
along
9:48
with
9:48
her
9:49
co
9:49
workers.
9:49
She's
9:49
not
9:50
worried
9:50
about
9:51
talking
9:51
to
9:52
them
9:52
one
9:53
on
9:53
one
9:54
about
9:55
a
9:55
play
9:55
that
9:56
her
9:56
co
9:56
worker
9:56
saw
9:57
three
9:57
days
9:57
ago
9:58
or
9:59
asking
9:59
her
10:00
co
10:00
worker
10:00
what
10:00
type
10:01
of
10:01
sandwich
10:01
she's
10:01
eating.
10:02
She
10:02
doesn't
10:02
freak
10:02
out
10:02
about
10:03
those
10:03
things.
10:04
She
10:04
is
10:04
again
10:05
orienting
10:06
you
10:06
right
10:06
back
10:06
to
10:07
performance
10:07
related
10:08
situations.
10:09
Now
10:10
I
10:10
would
10:10
also
10:10
love
10:11
to
10:11
understand
10:11
what
10:12
are
10:12
some
10:12
physical
10:12
symptoms
10:13
you
10:13
experience
10:14
when
10:15
you
10:15
are
10:15
in
10:16
these
10:16
performance
10:16
situations.
10:17
She's
10:17
already
10:18
shared
10:18
that
10:18
with
10:18
you,
10:18
right
10:19
I
10:19
would
10:19
want
10:20
to
10:20
know
10:20
how
10:20
long
10:20
you
10:21
dread
10:21
these
10:21
situations.
10:22
I
10:22
would
10:22
ask
10:23
her,
10:23
has
10:23
this,
10:24
how
10:24
has
10:24
this
10:24
impacted
10:25
your
10:26
career?
10:27
In
10:27
seeing
10:28
that
10:28
this
10:28
has
10:29
been
10:29
so
10:32
anxiety
10:32
provoking
10:33
for
10:33
you,
10:34
how
10:34
has
10:35
this
10:35
fear
10:36
impacted
10:36
your
10:36
career
10:37
or
10:37
your
10:37
relationships?
10:39
What
10:39
types
10:39
of
10:40
opportunities
10:41
have
10:41
you
10:42
avoided
10:42
as
10:43
a
10:43
result
10:43
of
10:44
this
10:44
fear
10:45
of
10:45
performing
10:46
in
10:46
front
10:46
of
10:47
other
10:47
people?
10:48
You
10:48
know,
10:48
how
10:49
deep
10:49
do
10:49
your
10:50
relationships
10:50
get,
10:50
now
10:51
that
10:51
you
10:51
think
10:51
about
10:51
it,
10:52
in
10:52
seeing
10:52
that
10:53
maybe
10:54
you're
10:54
hesitant
10:55
to
10:57
be
10:58
in
10:58
the
10:58
limelight
10:58
now
10:59
again,
10:59
she
10:59
might
10:59
say,
10:59
hey,
11:00
hey,
11:00
buddy.
11:00
Hey,
11:00
Dr.
11:01
Z.
11:02
I
11:02
have
11:02
no
11:03
problem
11:03
making
11:04
friends.
11:04
I
11:05
have
11:05
a
11:05
problem
11:06
giving
11:06
presentations.
11:07
I
11:07
have
11:07
a
11:08
problem
11:08
singing
11:09
the
11:09
national
11:09
anthem.
11:10
I
11:10
have
11:10
a
11:10
problem
11:11
accepting
11:12
promotions
11:13
that
11:13
put
11:13
me
11:13
in
11:14
positions
11:14
where
11:14
I
11:14
have
11:15
to
11:15
brief
11:15
people
11:16
and
11:16
preside
11:17
over
11:17
staff
11:17
meetings.
11:18
So
11:18
now
11:18
we're
11:18
understanding
11:19
that
11:19
not
11:20
only
11:20
is
11:20
this
11:20
distressing,
11:21
it's
11:21
also
11:22
impairing.
11:22
This
11:22
is
11:23
occupationally
11:23
impairing
11:24
because
11:25
she
11:25
has
11:25
distress.
11:27
It's
11:27
also
11:27
impairing
11:28
because
11:29
Carly
11:30
is
11:31
not
11:31
moving
11:31
up
11:32
the
11:32
totem
11:33
pole
11:33
in
11:33
the
11:34
library.
11:34
Do
11:34
you
11:34
become
11:35
the
11:35
manager
11:36
of
11:36
the
11:36
library,
11:37
the
11:37
deputy
11:37
manager
11:38
of
11:38
a
11:38
library?
11:39
I
11:39
don't
11:39
know
11:39
if
11:39
they
11:39
even
11:40
have
11:40
a
11:40
hierarchy.
11:40
It
11:40
could
11:41
just
11:41
be
11:41
this
11:42
flattened
11:43
hierarchy,
11:44
this
11:44
anarchy
11:45
of
11:45
librarians
11:46
that
11:46
just
11:46
go
11:46
around
11:47
making
11:47
sure
11:47
all
11:47
the
11:47
books
11:48
are
11:48
cattle
11:49
catalog.
11:49
I
11:49
have
11:49
no
11:50
idea.
11:50
But
11:50
the
11:50
bottom
11:51
line
11:51
is
11:51
if
11:51
you're
11:51
afraid
11:52
of
11:52
the
11:52
limelight,
11:53
if
11:53
it
11:53
causes
11:54
severe
11:54
anxiety
11:54
and
11:55
distress,
11:55
you
11:56
may
11:56
be
11:56
paying
11:56
for
11:56
it
11:57
in
11:57
some
11:57
way,
11:58
shape
11:58
or
11:58
form.
11:58
I
11:58
have
11:59
a
11:59
lot
11:59
of
11:59
friends
11:59
who
11:59
are
11:59
librarians.
12:00
Most
12:01
of
12:01
my
12:01
friends
12:01
are
12:01
librarians.
12:02
Okay,
12:02
so
12:02
this
12:03
is
12:03
not
12:03
disrespect
12:04
towards
12:04
librarians.
12:05
But
12:05
maybe
12:06
Carly
12:07
was
12:07
really
12:07
good
12:07
at
12:08
finance
12:08
or
12:09
she
12:09
wanted
12:09
to
12:09
be
12:09
a
12:10
lawyer.
12:10
And
12:10
because
12:10
she
12:11
was
12:11
so
12:11
petrified
12:12
of
12:12
speaking
12:13
in
12:13
front
12:13
of
12:13
a
12:13
jury,
12:14
she
12:14
said,
12:15
you
12:15
know
12:15
what,
12:15
I'm
12:15
just
12:15
going
12:16
to
12:16
hang
12:16
out
12:16
in
12:16
the
12:16
library
12:17
instead.
12:17
I'm
12:18
going
12:18
to
12:18
be
12:18
a
12:18
librarian.
12:19
I'll
12:19
make
12:19
60,
12:20
70k
12:20
a
12:20
year.
12:21
That's
12:21
fine.
12:22
It's
12:22
a
12:22
beautiful,
12:23
humble
12:23
career.
12:25
But
12:25
I'm
12:25
going
12:26
to
12:26
turn
12:26
down
12:27
being
12:27
a
12:27
high
12:27
powered
12:28
trial
12:28
attorney
12:28
because
12:29
I
12:30
can't
12:30
get
12:30
over
12:30
this
12:31
fear
12:31
of
12:31
talking
12:31
in
12:31
front
12:32
of
12:32
a
12:32
jury.
12:33
So
12:33
my
12:33
greater
12:34
point,
12:34
my
12:34
friends,
12:35
is
12:36
just
12:37
because
12:37
a
12:37
client,
12:38
just
12:38
because
12:38
a
12:38
patient
12:39
is
12:40
not
12:40
necessarily
12:41
in
12:41
distress
12:42
because
12:43
they
12:43
avoid
12:43
things
12:43
all
12:44
the
12:44
time.
12:44
If
12:45
Carly
12:45
never
12:45
puts
12:46
herself
12:46
in
12:46
these
12:46
situations,
12:47
you
12:47
could
12:47
say,
12:48
well,
12:48
okay,
12:48
she
12:48
doesn't
12:49
have
12:49
a
12:49
disorder
12:49
in
12:49
the
12:49
dsm.
12:51
Well,
12:52
okay,
12:52
she
12:53
might
12:53
not
12:53
be
12:53
in
12:53
distress,
12:53
but
12:54
there
12:54
is
12:54
impairment.
12:55
In
12:55
this
12:55
case,
12:56
there
12:56
might
12:56
be
12:56
a
12:56
little
12:56
bit
12:57
of
12:57
both.
12:57
Carly
12:58
is
12:58
going
12:58
to
12:58
go
12:58
ahead
12:58
and
12:59
try
12:59
and
12:59
give
12:59
this
12:59
eulogy
13:00
anyway.
13:01
Ask
13:02
about
13:02
impact,
13:03
how
13:03
does
13:03
this
13:03
impact
13:04
your
13:04
relationship?
13:04
How
13:05
does
13:05
this
13:05
impact
13:06
your
13:06
career?
13:07
Really
13:08
dig
13:08
and
13:08
get
13:08
the
13:08
patient
13:09
to
13:09
explore
13:10
in
13:10
the
13:10
quiet,
13:11
safe
13:11
space
13:11
of
13:12
your
13:12
office.
13:12
Get
13:12
them
13:12
to
13:13
explore
13:14
exactly
13:15
how
13:16
this
13:16
is
13:17
affecting
13:17
them.
13:17
The
13:17
ramifications
13:19
of
13:19
this
13:19
behavior
13:20
zero
13:20
in
13:20
on
13:21
what
13:21
else
13:22
this
13:22
could
13:22
be
13:22
other
13:22
than
13:23
social
13:23
anxiety.
13:23
We've
13:24
kind
13:24
of
13:24
ruled
13:24
out
13:25
generalized
13:26
anxiety
13:26
based
13:26
on
13:27
her
13:27
initial
13:28
comments.
13:28
She
13:29
doesn't
13:29
worry
13:29
about
13:29
other
13:29
things
13:30
she
13:30
stresses
13:30
for
13:31
weeks
13:31
at
13:31
a
13:31
time
13:32
but
13:32
before
13:32
these
13:33
events.
13:33
So
13:33
that's
13:33
pretty
13:34
concerning,
13:34
too.
13:34
It's
13:35
all
13:35
consuming.
13:36
And
13:36
she's
13:36
saying
13:36
in
13:36
between
13:37
these
13:37
eulogies
13:37
and
13:38
things
13:38
of
13:38
that
13:38
nature,
13:38
she's
13:39
not
13:39
that
13:39
anxious.
13:40
We're
13:40
really
13:40
zeroing
13:40
in
13:41
now.
13:41
Here's
13:41
another
13:41
thing
13:41
to
13:42
ask
13:42
Carly.
13:43
How
13:43
often
13:45
do
13:45
you
13:45
have
13:46
to
13:46
give
13:46
a
13:46
eulogy?
13:47
Hopefully
13:48
she
13:48
has
13:49
to
13:49
do
13:49
it
13:49
once
13:49
in
13:49
a
13:50
lifetime,
13:50
if
13:50
that.
13:51
Right.
13:51
But
13:52
if
13:52
she
13:53
works
13:53
at
13:53
a
13:53
funeral
13:53
home
13:54
or
13:55
if
13:55
she
13:55
has
13:56
some
13:56
other
13:56
job
13:57
where
13:57
her
13:57
job
13:57
is
13:58
to
13:58
sing
13:58
national
13:58
anthems
13:59
before
14:00
a
14:00
Yankees
14:01
game.
14:02
Not
14:02
that
14:02
that
14:02
would
14:03
be
14:03
a
14:03
compatible
14:04
job
14:04
for
14:04
Carly.
14:05
It's
14:05
probably
14:05
the
14:06
most
14:06
terrifying
14:07
job
14:08
she
14:08
could
14:08
possibly
14:09
apply
14:09
for.
14:10
But
14:11
you
14:11
get
14:11
my
14:11
point,
14:11
right?
14:11
If
14:12
Carly
14:13
doesn't
14:13
have
14:14
a
14:14
job
14:14
that
14:14
requires
14:15
a
14:15
lot
14:15
of
14:16
this,
14:16
just
14:17
tuck
14:17
that
14:17
in
14:17
your
14:18
back
14:18
pocket
14:18
for
14:18
now,
14:19
because
14:19
do
14:20
you
14:20
really
14:20
want
14:20
to
14:20
hit
14:20
her
14:20
with
14:21
a
14:21
medication
14:21
she
14:21
has
14:21
to
14:22
take
14:22
every
14:22
day
14:22
for
14:22
the
14:22
rest
14:23
of
14:23
her
14:23
life?
14:23
If
14:24
the
14:24
amount
14:24
of
14:24
distress
14:25
and
14:25
impairment
14:25
is
14:26
localized
14:27
to
14:27
just
14:27
a
14:28
few
14:28
events,
14:29
I
14:29
want
14:29
you
14:29
to
14:29
keep
14:29
that
14:30
in
14:30
your
14:30
back
14:30
pocket.
14:30
Our
14:31
next
14:31
segment
14:32
is
14:32
called
14:32
Lab
14:32
Rats.
14:33
This
14:33
segment,
14:34
we
14:34
investigate
14:34
which
14:35
kind
14:35
of
14:35
labs
14:36
may
14:36
be
14:37
necessary
14:38
to
14:38
figure
14:38
out
14:38
if
14:39
this
14:39
is
14:39
either
14:40
caused
14:40
by
14:41
or
14:41
exacerbated
14:42
by
14:43
labs
14:44
that
14:44
are
14:45
out
14:45
of
14:45
whack.
14:46
You
14:46
can
14:46
be
14:47
pretty
14:47
darn
14:47
sure
14:48
just
14:49
based
14:49
on
14:49
the
14:49
fact
14:49
that
14:50
it's
14:50
a
14:50
specific
14:52
circumstance
14:53
that's
14:54
worsening
14:55
her
14:55
anxiety,
14:55
that
14:56
this
14:56
is
14:56
likely
14:58
not
14:59
caused
15:00
by
15:00
a
15:01
wonky
15:01
laboratory
15:02
value.
15:02
Right?
15:03
We
15:03
can't
15:03
declare
15:04
that
15:04
officially,
15:05
but
15:06
we
15:06
can
15:06
reasonably
15:07
assume
15:07
that
15:07
it's
15:08
a
15:08
good
15:08
possibility.
15:09
Because
15:10
she's
15:10
not
15:10
telling
15:11
you.
15:11
Oh,
15:11
I'm
15:11
jittery
15:12
all
15:12
day,
15:12
every
15:12
day.
15:13
I
15:13
have
15:13
tremors
15:13
and
15:13
a
15:14
racing
15:14
heart
15:14
every
15:14
day,
15:15
all
15:15
day.
15:15
That
15:15
would
15:15
probably
15:16
speak
15:16
to
15:17
a
15:17
hyperthyroid.
15:19
Certainly
15:19
wouldn't
15:20
be
15:20
a
15:20
terrible
15:20
idea,
15:20
but
15:21
our
15:21
index
15:21
of
15:22
suspicion
15:22
for
15:22
a
15:22
wonky
15:23
thyroid
15:23
is
15:24
a
15:24
little
15:24
bit
15:24
lower.
15:25
Given
15:25
the
15:25
fact
15:26
that
15:26
Carly
15:27
doesn't
15:27
exhibit
15:27
these
15:28
physical
15:28
symptoms
15:28
outside
15:30
of
15:30
the
15:30
times
15:30
that
15:31
Gary
15:31
chokes
15:32
on
15:32
a
15:32
piece
15:32
of
15:32
peanut
15:33
brittle.
15:34
Now,
15:34
we
15:34
could
15:34
get
15:34
a
15:34
CBC
15:35
to
15:35
rule
15:35
out
15:35
anemia.
15:36
Anemia
15:36
can
15:36
cause
15:37
fatigue,
15:37
weakness,
15:37
and
15:38
shortness
15:38
of
15:38
breath,
15:38
which
15:39
might
15:39
impact
15:39
performance
15:40
or
15:40
be
15:40
misinterpreted
15:41
as
15:41
anxiety.
15:42
When
15:43
Carly
15:44
performs.
15:44
But
15:44
again,
15:44
those
15:45
symptoms
15:45
would
15:45
probably
15:46
be
15:46
experienced
15:46
at
15:46
rest
15:47
if
15:47
they're
15:47
problematic.
15:48
So
15:49
I
15:49
doubt
15:49
it.
15:49
But
15:49
we
15:50
can
15:50
go
15:50
ahead
15:50
and
15:50
have
15:50
fun
15:51
and,
15:51
and
15:52
order
15:53
a
15:53
cbc.
15:53
Now,
15:53
this
15:53
is
15:54
more
15:54
your
15:54
discretion.
15:55
It
15:55
all
15:55
depends
15:55
on
15:56
clinical
15:56
context.
15:57
I
15:57
probably
15:57
wouldn't
15:59
order
15:59
these
15:59
labs
16:00
outright
16:00
if
16:01
this
16:01
was
16:01
a
16:02
very
16:02
circumscribed
16:03
stressor,
16:05
given
16:05
what
16:05
we've
16:06
talked
16:06
about.
16:06
But
16:06
the
16:06
real
16:07
world's
16:07
a
16:07
little
16:07
muddier
16:08
than
16:08
this.
16:08
Use
16:08
your
16:08
discretion.
16:09
Some
16:10
folks
16:10
might
16:10
order
16:10
a
16:10
cmp,
16:11
right,
16:11
A
16:12
metabolic
16:12
panel,
16:13
just
16:13
to
16:13
look
16:13
at
16:13
liver
16:14
and
16:14
kidney
16:14
function.
16:15
This
16:15
is
16:16
something
16:17
that
16:17
is
16:17
more
16:17
of
16:18
a
16:18
rank
16:18
and
16:18
file
16:19
lab
16:19
that
16:19
you
16:19
would
16:19
order
16:20
just
16:20
to
16:20
make
16:20
sure
16:21
that
16:21
anything
16:22
that
16:22
you
16:22
do
16:22
prescribe
16:23
would
16:23
be
16:23
metabolized
16:25
in
16:25
a
16:25
way
16:26
that
16:26
if
16:27
the
16:27
patient
16:27
had
16:27
kidney
16:28
or
16:28
liver
16:28
problems,
16:29
you'd
16:29
want
16:29
to
16:29
make
16:29
sure
16:30
your
16:30
medications
16:30
are
16:30
metabolized
16:31
accordingly
16:32
without
16:32
any
16:33
adjustments
16:33
that
16:34
would
16:34
otherwise
16:35
affect
16:35
drug
16:35
metabolism.
16:36
And
16:37
you
16:37
could
16:37
optionally
16:38
get
16:38
a
16:38
baseline
16:38
EKG
16:39
if
16:39
Carly
16:40
was,
16:40
you
16:41
know,
16:41
a
16:41
little
16:41
bit
16:41
older
16:41
and
16:42
had
16:42
some
16:42
cardiac
16:42
symptoms
16:43
and
16:43
might,
16:44
might.
16:45
It
16:45
might
16:45
point
16:45
to
16:45
some,
16:46
you
16:46
know,
16:47
abnormal
16:47
findings
16:48
that
16:48
could
16:48
cause
16:49
chest
16:49
palpitations,
16:49
chest
16:50
pain,
16:50
shortness
16:50
of
16:50
breath,
16:51
or
16:52
symptoms
16:52
commonly
16:52
associated
16:53
with
16:53
panic
16:53
or
16:53
anxiety
16:54
attacks.
16:54
Now,
16:55
let's
16:55
say
16:55
we
16:55
got
16:56
these
16:56
labs
16:56
and
16:56
labs
16:57
are
16:57
normal.
16:57
A
16:58
lot
16:58
of
16:58
this
16:58
lab
16:58
suggestion
16:59
is
16:59
more
16:59
for
17:00
students
17:00
to
17:00
understand
17:01
what,
17:01
what
17:01
to
17:01
think
17:02
about.
17:02
Certainly
17:03
if
17:03
she
17:03
was
17:04
endorsing
17:04
generalized
17:05
anxiety
17:05
and
17:06
worry,
17:06
these
17:06
labs
17:07
would.
17:07
Would
17:08
definitely
17:08
be
17:08
a
17:08
better
17:09
idea
17:09
because,
17:10
you
17:10
know,
17:10
you
17:10
want
17:10
to
17:11
make
17:11
sure
17:11
that
17:12
you're
17:12
treating
17:12
the
17:13
lab.
17:13
If
17:13
the
17:13
lab
17:13
is
17:14
abnormal,
17:14
rather
17:15
than
17:15
you
17:15
go
17:15
down
17:15
this
17:15
whole
17:16
rabbit
17:16
hole,
17:16
you
17:16
prescribe
17:17
SSRIs
17:18
for
17:18
a
17:18
year,
17:19
and
17:19
the
17:19
whole
17:19
problem
17:20
was
17:20
a
17:20
hyperthyroid
17:21
the
17:21
whole
17:21
time.
17:22
Right.
17:22
It's
17:22
good
17:22
practice
17:23
to
17:23
always
17:23
think
17:24
like
17:24
a
17:24
lab
17:24
rat
17:25
before
17:25
you
17:26
go
17:26
into
17:27
the
17:27
next
17:27
segment,
17:28
which
17:28
is
17:28
called
17:28
the
17:29
rule
17:29
out.
17:29
Rodeo
17:31
labs
17:31
came
17:31
back
17:31
normal.
17:33
Our
17:33
job,
17:34
based
17:34
on
17:34
all
17:35
the
17:35
information
17:35
we
17:35
have,
17:36
is
17:36
to
17:36
start
17:37
ruling
17:37
things
17:38
out.
17:38
Let's
17:38
say
17:38
we
17:38
talked
17:39
to
17:39
Carly.
17:39
We've
17:39
asked
17:40
the
17:40
questions,
17:40
we've
17:41
got
17:41
the
17:41
information
17:41
we
17:42
need.
17:42
Now
17:42
we're
17:42
thinking
17:42
in
17:42
our
17:43
minds,
17:43
what
17:43
do
17:44
we
17:44
rule
17:44
out
17:44
here?
17:45
What's
17:45
the
17:46
issue?
17:46
What
17:46
do
17:46
we
17:46
do?
17:47
It's
17:47
pretty
17:47
clear
17:48
right
17:48
now
17:48
that
17:49
Carly
17:50
is
17:50
dealing
17:51
with
17:51
some
17:51
kind
17:51
of
17:52
social
17:52
anxiety
17:53
disorder.
17:54
This
17:54
is
17:54
social
17:54
in
17:55
nature.
17:55
This
17:55
does
17:55
not
17:56
happen
17:56
when
17:56
she's
17:56
alone.
17:57
This
18:00
is
18:00
happening
18:01
exclusively
18:01
in
18:02
the
18:02
context
18:03
where
18:03
she
18:04
could
18:04
be
18:04
negatively
18:05
perceived
18:06
or
18:06
evaluated.
18:07
It's
18:08
fair
18:08
to
18:08
say
18:08
we
18:08
could
18:08
probably
18:09
rule
18:09
out
18:09
generalized
18:10
anxiety
18:10
disorder
18:11
at
18:11
this
18:11
point.
18:12
It
18:12
just
18:12
doesn't
18:13
seem
18:13
likely
18:13
that
18:14
she
18:14
has
18:14
it.
18:15
Her
18:15
worries
18:15
are
18:15
too
18:16
specific
18:16
and
18:16
not
18:17
spread
18:17
across
18:17
multiple
18:18
life
18:18
domains
18:18
like
18:19
finances,
18:19
health
18:19
or
18:20
safety.
18:21
She
18:21
also
18:21
says
18:21
she
18:22
does
18:22
not
18:22
worry
18:22
most
18:23
days.
18:23
With
18:23
generalized
18:24
anxiety
18:24
disorder,
18:25
you
18:25
have
18:25
to
18:25
worry
18:26
most
18:26
days
18:26
for
18:27
the
18:27
last
18:27
six
18:27
months.
18:27
That
18:28
is
18:28
not
18:28
the
18:28
case
18:28
with
18:28
her.
18:29
She
18:29
goes
18:29
to
18:29
Applebee's,
18:31
she
18:32
is
18:33
not
18:33
nervous
18:34
or
18:34
on
18:34
edge
18:34
as
18:34
a
18:35
librarian.
18:36
Most
18:36
days
18:37
she's
18:37
actually
18:37
pretty
18:37
calm.
18:38
She's
18:38
not
18:38
very
18:38
restless.
18:39
Her
18:40
sleep
18:40
and
18:40
appetite
18:41
are
18:41
very
18:42
robust.
18:43
Outside
18:43
of
18:44
worrying
18:44
about
18:44
giving
18:45
a
18:45
eulogy,
18:45
she's
18:46
not
18:46
losing
18:46
sleep.
18:47
Maybe
18:47
now
18:47
she
18:47
is
18:47
a
18:47
little
18:48
bit
18:48
and
18:48
that
18:48
can
18:48
throw
18:48
you
18:48
off.
18:49
Maybe
18:49
now
18:49
she's
18:49
going
18:49
to
18:49
tell
18:49
you
18:50
through
18:50
two
18:50
to
18:50
three
18:50
hours
18:51
a
18:51
night.
18:51
So
18:51
I'm
18:52
ruminating
18:52
about
18:52
this.
18:53
How
18:53
am
18:53
I
18:53
going
18:53
to
18:53
do,
18:54
what
18:54
if
18:54
I
18:54
melt
18:54
down?
18:55
What
18:55
if
18:55
I
18:55
make
18:55
a
18:55
mistake?
18:56
But
18:56
outside
18:57
of
18:57
that,
18:57
the
18:57
key
18:58
for
18:58
you
18:58
as
18:58
a
18:58
clinician
18:59
is
18:59
to
18:59
understand
19:00
the
19:00
nature
19:01
of
19:01
that
19:01
anxiety.
19:02
The
19:02
timing,
19:03
how
19:03
long
19:04
does
19:04
it
19:04
last,
19:04
when
19:05
did
19:05
it
19:05
start,
19:05
what
19:06
makes
19:06
it
19:06
worse?
19:07
That's
19:07
going
19:07
to
19:07
help
19:07
you
19:08
rule
19:08
out
19:08
things
19:08
like
19:09
generalized
19:09
anxiety
19:10
disorder.
19:11
Now
19:11
you
19:11
could
19:12
wonder
19:12
if
19:12
she
19:12
has
19:12
an
19:13
avoidant
19:13
personality
19:14
disorder,
19:14
right?
19:14
You
19:15
could
19:15
wonder
19:15
what
19:15
her
19:17
posture
19:17
is
19:17
towards
19:18
people
19:19
at
19:19
her
19:19
baseline.
19:20
Is
19:20
she
19:20
shy?
19:21
Is
19:21
she
19:22
petrified
19:23
of
19:24
looking
19:24
bad
19:24
in
19:25
front
19:25
of
19:25
other
19:25
people?
19:25
Where
19:26
she's
19:26
very
19:26
submissive,
19:27
wants
19:28
others
19:28
approval
19:29
and
19:29
is
19:30
very
19:30
nervous
19:31
in
19:31
social
19:31
situations,
19:32
has
19:33
chronic
19:33
low
19:33
self
19:34
esteem,
19:35
pervasive
19:35
social
19:36
inhibition?
19:37
If
19:37
that's
19:38
the
19:38
case,
19:38
that
19:39
would
19:39
be
19:39
across
19:40
all
19:41
types
19:41
of
19:42
relationships
19:42
or
19:43
domains,
19:43
not
19:43
just
19:44
perverse
19:44
performing
19:44
in
19:45
front
19:45
of
19:45
a
19:45
group
19:45
of
19:45
people,
19:46
right?
19:46
So
19:47
it
19:47
just
19:47
doesn't
19:47
really
19:48
look
19:48
like
19:48
that
19:48
because
19:49
again,
19:49
this
19:49
is
19:49
not
19:49
most
19:50
social
19:50
interactions.
19:50
If
19:51
she
19:51
was
19:51
shy,
19:52
socially
19:53
inhibited
19:53
in
19:53
most
19:53
social
19:54
interactions,
19:55
then
19:55
I
19:55
would
19:56
definitely
19:56
worry
19:56
more
19:57
about
19:57
avoidant
19:57
personality
19:58
disorder.
19:58
We'll
19:59
do
19:59
a
19:59
deeper
19:59
dive
19:59
on
20:00
that
20:00
in
20:00
other
20:00
case
20:00
studies,
20:01
but
20:01
it
20:01
just
20:01
doesn't
20:01
look
20:02
like
20:02
it
20:03
now.
20:03
Panic
20:03
disorder
20:04
yet.
20:06
You
20:06
ask
20:06
Carla
20:07
and
20:07
she
20:07
says
20:07
sure.
20:08
When
20:09
I
20:09
was
20:10
18,
20:10
I
20:10
had
20:10
to
20:10
sing
20:10
the
20:11
national
20:11
anthem
20:11
at
20:11
a
20:11
Little
20:12
league
20:12
game
20:12
and
20:13
I
20:13
had
20:13
a
20:13
complete
20:13
meltdown.
20:14
I
20:14
got
20:14
short
20:14
of
20:15
breath,
20:15
I
20:15
got
20:15
red
20:15
in
20:16
the
20:16
face,
20:16
I
20:16
had
20:16
a
20:16
choking
20:17
sensation.
20:18
Midway
20:18
through
20:18
the
20:19
anthem,
20:19
I
20:20
collapsed
20:21
and
20:21
I
20:22
was
20:22
mortified.
20:23
Now
20:23
that
20:24
could
20:24
look
20:24
like
20:24
a
20:24
panic
20:25
attack.
20:25
It
20:26
has
20:26
all
20:26
the
20:26
hallmark
20:26
physiological
20:27
features
20:28
of
20:28
a
20:28
panic
20:28
attack.
20:29
But
20:29
again,
20:29
if
20:30
you
20:30
get
20:30
to
20:31
the
20:31
root
20:32
cause,
20:32
it's
20:33
the
20:33
performative
20:34
nature
20:35
of
20:36
what
20:36
is
20:36
sparking
20:36
her
20:37
anxiety.
20:37
Panic
20:38
attacks,
20:38
or
20:38
at
20:38
least
20:38
panic
20:38
disorder
20:39
definitionally
20:40
in
20:41
the
20:41
DSM
20:41
5
20:42
is
20:43
more
20:43
random.
20:44
It's
20:44
unexpected,
20:45
it
20:45
comes
20:45
out
20:46
of
20:46
the
20:46
blue,
20:47
they're
20:47
reoccurring
20:48
and
20:48
you
20:48
avoid
20:48
places,
20:49
people
20:49
or
20:49
things
20:50
where
20:50
you
20:50
think
20:50
you
20:50
might
20:50
get
20:51
another
20:51
panic
20:51
attack
20:51
in
20:52
the
20:52
future.
20:52
There's
20:53
no
20:53
real
20:53
evidence
20:53
of
20:54
that
20:54
with
20:54
Carly
20:54
right
20:55
now.
20:55
She
20:55
has
20:56
stated
20:56
that
20:56
that's
20:56
not
20:57
really
20:57
the
20:57
case.
20:57
And
20:58
if
20:58
it
20:58
was,
20:58
she
20:58
would
20:59
be
20:59
focused
20:59
much
20:59
more
21:00
on
21:01
having
21:01
that
21:01
attack.
21:02
And
21:02
see,
21:02
that's
21:03
where
21:03
we
21:03
really
21:03
get
21:03
to
21:04
the
21:04
core
21:04
of
21:04
these
21:04
psychiatric
21:05
diagnoses.
21:06
Always
21:06
think,
21:06
what
21:07
is
21:07
the
21:07
worm
21:07
at
21:07
the
21:08
core?
21:08
The
21:08
worm
21:09
at
21:09
the
21:09
core
21:10
has
21:10
not
21:10
been
21:11
Carly
21:11
fearing
21:12
another
21:12
panic
21:12
attack
21:12
or
21:13
she
21:13
would
21:13
have
21:14
literally
21:14
told
21:14
you
21:15
that.
21:15
I'm
21:15
afraid
21:16
of
21:16
when
21:16
my
21:16
next
21:17
attack
21:17
is
21:17
going
21:17
to
21:17
come.
21:18
This
21:18
is
21:19
what
21:19
it
21:19
looks
21:19
like.
21:19
I
21:19
get
21:20
really
21:20
short
21:20
of
21:20
breath.
22:15
Her
22:16
fear
22:16
is
22:17
the
22:17
groups
22:17
of
22:17
people
22:18
that
22:18
could
22:18
potentially
21:24
evaluate
22:19
her
22:19
in
22:20
a
22:20
negative
22:20
fashion.
22:21
The
22:21
origin
22:22
or
22:22
stimulus
22:22
of
22:23
her
22:23
fear
22:23
is
22:23
not
22:23
the
22:23
actual
22:24
core
22:24
symptoms.
22:25
Those
22:25
are
22:25
secondary.
22:26
The
22:26
symptoms
22:26
she
22:27
experiences
22:28
are
22:28
secondary
22:29
to
22:30
the
22:31
actual
22:31
stimulus,
22:32
which
22:32
are
22:32
the
22:32
people
22:32
who
22:33
are
22:33
making
22:33
her
22:33
nervous.
22:34
So
22:34
again,
22:34
that
22:35
kind
22:35
of
22:35
rules
22:35
out
22:35
panic
22:36
disorder,
22:36
at
22:36
least
22:36
for
22:37
now.
22:37
I
22:37
would
22:37
keep
22:37
these
22:38
all
22:38
in
22:38
your
22:38
back
22:38
pocket
22:39
because
22:39
there's
22:39
a
22:39
lot
22:39
of
22:39
comorbidity
22:40
floating
22:40
around
22:41
and
22:41
you
22:41
are
22:41
not
22:41
going
22:42
to
22:42
know
22:42
or
22:43
really
22:43
appreciate
22:44
the
22:44
full
22:44
context
22:45
of
22:45
your
22:45
patient's
22:45
life
22:46
story
22:46
in
22:46
that
22:46
first
22:47
60
22:47
or
22:47
90
22:47
minutes.
22:48
You
22:48
just
22:48
can't
22:48
and
22:48
you
22:48
just
22:49
won't.
22:49
So
22:50
don't
22:50
even
22:51
try.
22:51
Instead
22:52
of
22:52
just
22:52
keep
22:52
these
22:52
in
22:53
your
22:53
back
22:53
pocket.
22:54
Don't
22:54
send
22:54
your
22:54
suspects
22:55
home.
22:56
Keep
22:56
them
22:57
at
22:57
the
22:57
police
22:57
station,
22:58
but
22:58
be
22:59
okay
22:59
with
22:59
letting
23:00
them
23:00
go.
23:00
And
23:00
definitely
23:01
think
23:01
about
23:01
putting
23:02
handcuffs
23:03
on
23:03
the
23:04
social
23:04
anxiety
23:05
suspect
23:05
because
23:06
that
23:06
looks
23:06
like
23:06
where
23:07
we're
23:07
going
23:07
here
23:08
now,
23:08
the
23:08
rule
23:09
out
23:09
rodeo.
23:09
And
23:10
it's
23:10
not
23:10
just
23:10
about
23:11
ruling
23:11
out
23:12
diagnoses
23:13
or.
23:14
Well,
23:14
it
23:14
is
23:14
and
23:14
it
23:14
isn't,
23:15
right?
23:15
But
23:15
you
23:15
also
23:15
want
23:16
to
23:16
look
23:16
at
23:16
substances.
23:16
Now
23:17
she
23:17
gave
23:17
you
23:17
a
23:17
totally
23:19
clean
23:19
bill
23:20
when
23:20
it
23:21
comes
23:21
to
23:21
substances.
23:22
You
23:22
all
23:22
remember
23:22
what
23:22
raised
23:23
a
23:23
red
23:23
flag
23:24
with
23:24
Carly.
23:24
Substance
23:25
use.
23:25
Caffeine
23:26
is
23:26
a
23:27
substance.
23:27
One
23:27
of
23:28
the
23:28
most
23:28
abused
23:28
drugs
23:29
in
23:29
the
23:29
world.
23:29
It's
23:29
technically
23:30
a
23:30
drug.
23:30
It's
23:30
psychoactive.
23:31
It
23:31
changes
23:31
how
23:32
you
23:32
process
23:32
information.
23:33
Carly
23:34
talked
23:34
to
23:34
you
23:34
about
23:34
death
23:35
wish
23:35
coffee.
23:35
Now
23:36
it
23:36
is
23:36
so
23:37
important
23:37
for
23:37
you,
23:37
my
23:38
friends,
23:39
that
23:39
you
23:40
get
23:41
a
23:41
good
23:41
inventory
23:42
of
23:42
everything
23:43
your
23:43
patient
23:44
is
23:44
trying
23:44
to
23:44
do
23:45
to
23:46
get
23:46
by
23:47
her
23:47
day,
23:47
whether
23:48
it's
23:48
supplements,
23:49
coffee,
23:49
her
23:50
diet,
23:50
her,
23:51
her
23:51
sleep
23:51
patterns,
23:52
everything.
23:53
You
23:53
want
23:53
to
23:53
be
23:53
a
23:54
detective.
23:54
You
23:54
want
23:55
to
23:55
leave
23:55
no
23:55
stone
23:55
unturned.
23:56
Now
23:56
she
23:56
told
23:56
you
23:56
death
23:57
wish
23:57
coffee.
23:58
Now,
23:58
you
23:58
don't
23:58
need
23:59
a
23:59
degree
24:00
in
24:01
coffee
24:02
brewing
24:02
or
24:03
coffee
24:03
roasting.
24:04
You
24:04
don't
24:04
need
24:04
to
24:04
be
24:04
some
24:05
coffee
24:05
expert
24:06
to
24:06
appreciate
24:07
the
24:07
fact
24:07
that
24:07
death
24:08
wish
24:08
coffee
24:08
probably
24:10
is
24:10
going
24:10
to
24:10
give
24:10
you
24:10
a
24:11
panic
24:11
attack
24:12
after
24:12
like
24:12
half
24:13
a
24:13
cup.
24:13
It
24:13
has
24:13
728
24:14
milligrams
24:15
of
24:15
caffeine.
24:15
That's
24:16
like
24:16
two
24:16
panic
24:17
attacks
24:17
in
24:17
a
24:17
cup
24:18
of
24:18
coffee.
24:19
Now,
24:19
when
24:19
you
24:19
ask
24:19
Carly
24:20
what
24:20
would
24:20
be
24:21
the
24:21
questions
24:21
you
24:21
wanted
24:21
to
24:22
ask?
24:22
How
24:22
often
24:22
are
24:22
you
24:23
drinking
24:23
death
24:23
wish
24:23
coffee?
24:24
How
24:25
many
24:25
cups
24:25
do
24:25
you
24:25
have?
24:26
How
24:26
do
24:26
you
24:26
feel
24:26
afterwards?
24:27
Right.
24:28
How
24:28
does
24:28
it
24:28
make
24:28
you
24:28
feel?
24:29
Now
24:30
you
24:30
ask
24:31
Carly
24:31
these
24:31
questions
24:31
and
24:32
she
24:32
tells
24:32
you,
24:32
oh,
24:32
you
24:33
know,
24:33
I
24:33
take
24:33
that
24:33
like
24:34
maybe
24:34
once
24:35
every
24:35
three
24:35
weeks
24:35
when
24:36
I
24:36
have
24:36
a
24:36
tough
24:36
day
24:36
at
24:36
the
24:37
library.
24:37
I
24:37
don't
24:37
drink
24:38
it
24:38
regularly.
24:38
Okay.
24:39
Keep
24:39
it
24:40
in
24:40
your
24:40
back
24:40
pocket.
24:41
That's
24:41
an
24:41
insane
24:42
amount
24:42
of
24:42
caffeine
24:43
that
24:43
could
24:44
kill
24:44
a
24:44
small
24:44
horse.
24:45
But
24:45
it
24:46
may
24:46
not
24:46
be
24:46
the
24:47
principal
24:47
instigating
24:48
factor
24:49
here,
24:49
especially
24:49
because
24:50
she
24:50
told
24:50
you
24:50
in
24:51
the
24:51
past
24:52
she
24:52
sang
24:53
the
24:53
national
24:53
anthem
24:54
and
24:54
was
24:55
so
24:55
consumed
24:55
with
24:56
anxiety
24:56
that
24:56
she
24:56
collapsed
24:58
onto
24:58
the
24:58
pitcher's
24:59
mound.
25:00
So
25:00
it's
25:00
unlikely
25:01
that
25:01
it's
25:01
the
25:01
coffee
25:02
that's
25:03
causing
25:04
this
25:04
feeling
25:04
here
25:04
that
25:05
has
25:05
been
25:05
present
25:06
for
25:06
a
25:06
very
25:06
long
25:06
time.
25:07
She's
25:07
passed
25:08
over
25:08
multiple
25:09
job
25:09
opportunities
25:10
because
25:10
of
25:10
it.
25:10
It's
25:11
unlikely
25:11
that
25:11
it's
25:12
the
25:12
coffee,
25:12
but
25:12
you
25:13
definitely
25:13
should
25:14
educate
25:14
your
25:14
patient
25:15
that
25:16
if
25:16
she's
25:16
having
25:17
that
25:17
much
25:17
death
25:17
wish
25:17
coffee
25:18
beforehand,
25:18
she
25:18
might
25:19
have
25:19
a
25:19
panic
25:19
attack
25:19
just
25:20
performing
25:21
her
25:21
order
25:21
in
25:22
front
25:22
of
25:22
a
25:22
waitress.
25:22
It's
25:23
good
25:23
to
25:23
educate,
25:23
but
25:24
because
25:24
she
25:24
doesn't
25:24
do
25:24
it
25:25
every
25:25
day,
25:25
it's
25:25
unlikely
25:26
that
25:26
Carly
25:27
is
25:27
dealing
25:27
with
25:28
death
25:28
wish
25:28
coffee
25:30
substance.
25:31
Caffeine
25:32
induced
25:32
something
25:33
here.
25:33
This
25:34
looks
25:34
more
25:34
like
25:34
a
25:35
social
25:35
anxiety
25:35
disorder
25:36
that
25:36
is
25:36
in
25:36
no
25:37
part
25:37
being
25:37
helped
25:38
by
25:38
death
25:38
wish
25:39
coffee.
25:40
So.
25:40
And
25:41
you
25:41
remember
25:41
because
25:41
it's
25:42
good
25:42
to
25:42
really
25:42
look
25:43
under
25:43
the
25:43
rug
25:43
and
25:43
rule
25:43
this
25:44
out.
25:44
Because
25:44
coffee
25:44
causes
25:45
tremors,
25:45
palpitations
25:46
and
25:46
jitteriness,
25:47
it
25:47
can
25:47
cloud
25:48
your
25:48
diagnostic
25:49
picture
25:49
as
25:49
well.
25:50
And
25:50
you
25:50
might
25:50
not
25:50
even
25:51
really
25:51
know
25:51
what's
25:52
going
25:52
on.
25:52
So
25:53
definitely
25:53
rule
25:54
that
25:54
out,
25:54
my
25:55
friends.
25:55
Carly
25:55
says
25:56
she's
25:56
not
25:56
depressed
25:57
outside
25:57
of
25:57
these
25:59
eulogies
25:59
that
25:59
she
25:59
dreads.
26:00
She
26:01
doesn't
26:01
feel
26:01
depressed
26:01
or
26:02
down
26:02
or
26:02
sad
26:03
or
26:03
missing
26:03
sleep
26:03
or
26:04
appetite's
26:04
just
26:04
fine
26:05
outside
26:05
of
26:05
this.
26:05
So
26:05
we're
26:06
really
26:06
zeroing
26:06
this,
26:07
really
26:08
zeroing
26:08
in
26:08
on
26:08
this.
26:09
Now,
26:09
one
26:10
way
26:10
you
26:10
can
26:10
screen
26:12
her
26:12
social
26:12
anxiety
26:13
disorder
26:13
is
26:14
the
26:14
mini
26:14
Social
26:15
Phobia
26:15
Inventory.
26:16
The
26:16
mini
26:16
Spin.
26:17
It's
26:17
a
26:17
concise
26:18
three
26:18
question
26:18
screening
26:19
tool,
26:19
highly
26:19
effective
26:20
for
26:20
diagnosing
26:21
social
26:21
anxiety,
26:22
demonstrating
26:22
around
26:23
a
26:23
90%
26:23
screening
26:24
accuracy.
26:25
There's
26:25
three
26:26
questions
26:26
involved.
26:26
You
26:27
can
26:28
have
26:28
access
26:28
to
26:29
these
26:29
slide
26:29
decks
26:30
and
26:30
more
26:30
pearls.
26:30
There's
26:31
so
26:31
many
26:31
more
26:31
pearls
26:32
and
26:32
screening
26:32
tools
26:33
and
26:33
important
26:34
elements
26:34
to
26:35
your
26:35
practice.
26:35
If
26:35
you
26:35
become
26:36
a
26:36
Patreon
26:36
member,
26:37
you'll
26:37
get
26:37
a
26:37
full
26:38
slide
26:38
deck
26:38
of
26:38
this
26:38
case
26:39
study
26:39
chock
26:39
full
26:39
of
26:40
pearls,
26:40
including
26:41
the
26:41
screening
26:42
Tools,
26:42
including
26:43
bonus
26:44
case
26:44
studies
26:45
on
26:45
the
26:45
side.
26:45
There's
26:46
more
26:46
where
26:46
that
26:46
comes
26:46
from.
26:47
So
26:48
don't
26:48
forget,
26:49
try
26:49
to
26:49
become
26:49
a
26:49
Patreon
26:50
member.
26:50
It's
26:50
well
26:50
worth
26:51
the
26:52
the
26:52
membership.
26:53
We
26:53
try
26:53
to
26:53
keep
26:53
things
26:53
nice
26:54
and
26:54
affordable
26:54
for
26:54
the
26:54
students.
26:55
Moving
26:56
on,
26:56
there
26:56
is
26:56
that
26:56
mini
26:57
social
26:57
phobia
26:58
inventory,
26:58
mini
26:59
spin
27:00
and
27:00
three
27:00
question
27:01
screenings
27:01
tool.
27:02
90%
27:02
screening
27:03
accuracy.
27:04
One
27:05
question
27:05
is
27:05
does
27:06
fear
27:06
of
27:06
embarrassment
27:07
cause
27:07
you
27:07
to
27:07
avoid
27:07
doing
27:08
things
27:08
or
27:08
speaking
27:08
to
27:09
people?
27:09
What
27:09
a
27:10
high
27:10
yield
27:10
psychiatric
27:11
question.
27:12
Absolutely
27:12
critical
27:13
to
27:13
ask
27:13
a
27:13
question
27:13
like
27:14
that
27:14
to
27:14
understand
27:15
the
27:15
degree
27:15
of
27:16
impairment
27:16
or
27:16
distress.
27:17
Do
27:18
you
27:18
avoid
27:18
activities
27:18
in
27:18
which
27:19
you
27:19
are
27:19
the
27:19
center
27:19
of
27:19
attention,
27:20
even
27:20
if
27:20
these
27:20
activities
27:21
are
27:21
enjoyable?
27:21
I
27:22
love
27:22
that
27:22
question.
27:23
I
27:23
will
27:23
leave
27:24
the
27:24
third
27:24
question
27:24
in
27:25
our
27:25
Patreon
27:25
for
27:26
you
27:26
to
27:26
peruse
27:27
later.
27:27
My
27:28
friends,
27:28
there's
27:28
another
27:29
screening
27:29
tool
27:29
we
27:29
go
27:30
over
27:30
in
27:31
our
27:31
Patreon
27:31
membership
27:32
account
27:32
that's
27:33
super
27:33
important
27:33
for
27:33
social
27:34
anxiety.
27:34
I
27:34
highly
27:35
recommend
27:35
you
27:37
become
27:37
a
27:37
member
27:38
because
27:38
we
27:38
can't
27:39
get
27:39
into
27:39
every
27:39
detail
27:40
on
27:40
the
27:40
podcast
27:40
today,
27:41
but
27:42
we
27:42
try
27:42
to
27:42
cover
27:42
the
27:43
most
27:43
important
27:43
stuff.
27:44
Now
27:44
let's
27:44
get
27:44
into
27:44
social
27:45
anxiety
27:45
disorder.
27:45
The
27:46
diagnostic
27:46
criteria.
27:48
Just
27:48
so
27:48
we're
27:48
all
27:48
aware
27:49
of
27:49
what
27:49
we're
27:49
looking
27:49
at,
27:50
right?
27:50
The
27:50
core
27:50
criteria
27:51
is
27:51
a
27:51
marked
27:52
fear
27:52
of
27:53
anxiety
27:53
or
27:53
scrutiny
27:55
in
27:55
social
27:55
situations
27:56
in
27:56
which
27:56
the
27:56
individual
27:57
is
27:57
exposed
27:57
to
27:58
possible
27:58
scrutiny
27:59
by
27:59
others.
27:59
Examples
28:00
might
28:00
include
28:01
having
28:01
a
28:02
conversation,
28:02
meeting
28:03
unfamiliar
28:04
people,
28:04
being
28:04
observed
28:05
even
28:05
when
28:05
you're
28:05
eating
28:06
or
28:06
drinking,
28:06
performing
28:07
in
28:07
front
28:07
of
28:07
others,
28:07
giving
28:08
a
28:08
speech.
28:08
And
28:08
in
28:08
this
28:09
case
28:09
that
28:09
would
28:09
be
28:09
Carly.
28:10
And
28:10
in
28:10
children,
28:11
anxiety
28:11
must
28:12
occur
28:12
in
28:12
peer
28:12
settings
28:13
and
28:13
not
28:13
just
28:13
interactions
28:14
with
28:14
adults.
28:14
Lord
28:15
knows
28:15
we'd
28:15
all
28:16
be
28:16
diagnosed
28:16
with
28:16
a
28:16
social
28:17
anxiety
28:17
disorder
28:18
if
28:18
we
28:18
were
28:19
if
28:19
it
28:19
was
28:19
judged
28:20
based
28:20
on
28:20
how
28:20
afraid
28:21
we
28:21
are
28:21
of
28:21
adults.
28:22
So
28:23
that's
28:23
a
28:23
cool
28:23
little
28:23
pearl
28:24
to
28:24
know
28:24
for
28:24
children.
28:25
Now,
28:26
the
28:26
key
28:27
for
28:27
Criterion
28:28
B
28:28
is
28:28
that
28:28
the
28:28
individual
28:29
fears
28:29
they
28:29
will
28:30
act
28:30
in
28:30
a
28:30
way
28:31
or
28:31
show
28:31
anxiety
28:32
symptoms
28:32
that
28:32
will
28:32
be
28:32
negatively
28:33
evaluated,
28:33
humiliating
28:34
or
28:34
embarrassing
28:35
that
28:35
will
28:36
lead
28:36
to
28:36
the
28:36
rejection
28:37
or
28:37
offense
28:38
of
28:38
others.
28:39
Social
28:39
anxiety
28:40
almost
28:40
always
28:40
provokes
28:41
fear
28:41
or
28:41
anxiety
28:42
in
28:43
children
28:43
that
28:43
can
28:43
look
28:43
like
28:43
crying,
28:44
tantrums,
28:45
freezing,
28:46
clinging,
28:46
shrinking,
28:47
or
28:47
failing
28:47
to
28:48
speak
28:48
in
28:48
social
28:48
situations.
28:49
This
28:50
is
28:50
really
28:50
important
28:50
for
28:51
all
28:51
of
28:51
us
28:51
to
28:51
remember.
28:52
Social
28:52
situations
28:53
are
28:53
avoided
28:54
or
28:54
endured
28:55
with
28:55
intense
28:55
fear
28:56
or
28:56
anxiety.
28:57
That's
28:57
key
28:58
because
28:58
it's
28:59
a
28:59
lot
28:59
harder
28:59
for
28:59
us
29:00
to
29:00
understand
29:00
what
29:00
the
29:01
patient
29:01
is
29:01
avoiding.
29:01
That
29:02
comes
29:02
back
29:02
to
29:03
why
29:03
asking
29:03
questions
29:04
is
29:04
so
29:04
important.
29:05
You
29:05
won't
29:05
really
29:05
sniff
29:06
this
29:06
out
29:06
in
29:06
the
29:06
DSM
29:07
unless
29:08
you
29:08
know
29:08
how
29:08
to
29:08
ask
29:08
about
29:09
what
29:09
these
29:09
patients
29:10
avoid.
29:10
And
29:11
you
29:11
got
29:11
to
29:11
get
29:11
them
29:11
thinking.
29:12
Not
29:12
all
29:12
of
29:12
them
29:12
are
29:12
consciously
29:13
aware
29:13
of
29:13
everything
29:14
they've
29:14
avoided
29:14
in
29:14
their
29:15
lives.
29:15
And
29:15
what
29:15
their
29:16
lives
29:16
could
29:16
have
29:16
looked
29:17
like
29:17
if
29:17
they
29:17
hadn't
29:18
been
29:18
afraid
29:19
of
29:19
this
29:19
stuff.
29:20
Right.
29:20
If
29:20
this
29:20
wasn't
29:21
at
29:21
the
29:21
forefront
29:21
of
29:21
their
29:22
anxiety.
29:22
So
29:23
again,
29:23
the
29:23
power
29:23
of
29:24
questions.
29:24
That's
29:24
why
29:24
we
29:25
do
29:25
our
29:25
Q
29:25
Tips
29:26
segment
29:26
of
29:27
our
29:27
episode.
29:27
Very
29:28
important.
29:28
I
29:28
so
29:28
encourage
29:29
all
29:29
of
29:29
you
29:29
to
29:29
email
29:30
me
29:30
in
29:30
the
29:30
show
29:30
notes.
29:30
I
29:31
have
29:31
a
29:31
link
29:31
for
29:31
email.
29:32
Email
29:32
me
29:33
and
29:33
share
29:34
your
29:34
high
29:34
yield
29:34
questions
29:35
that
29:35
you
29:35
love
29:35
to
29:35
ask
29:36
when
29:36
it
29:36
comes
29:36
to
29:36
any
29:37
of
29:37
these
29:37
diagnoses.
29:38
But
29:38
let's
29:38
start
29:39
with
29:39
social
29:39
anxiety.
29:40
Please
29:41
email
29:41
me
29:41
your
29:41
high
29:41
yield
29:42
questions.
29:42
I
29:42
would
29:43
love
29:43
to
29:43
share
29:44
the
29:44
high
29:44
yield
29:44
questions
29:45
you
29:45
have
29:45
in
29:46
our
29:46
next
29:46
episode
29:47
and
29:47
even
29:47
include
29:47
them
29:48
in
29:48
our
29:48
Patreon
29:49
membership
29:49
as
29:50
part
29:50
of
29:50
a
29:50
deeper
29:51
kind
29:51
of
29:52
Q
29:52
Tips
29:52
club
29:53
where
29:53
we
29:53
can
29:53
compile
29:54
a
29:54
list
29:54
of
29:54
the
29:55
best
29:56
questions,
29:56
the
29:57
most
29:57
high
29:57
yield
29:57
questions.
29:58
That
29:58
would
29:58
be
29:58
great.
29:59
The
29:59
Q
29:59
Tips
30:00
club.
30:01
I'll
30:01
create
30:01
it.
30:02
Now
30:03
remember,
30:04
folks,
30:04
in
30:05
social
30:05
anxiety
30:06
disorder,
30:06
the
30:07
fear
30:07
or
30:07
anxiety
30:08
is
30:08
out
30:09
of
30:09
proportion
30:10
to
30:10
the
30:10
actual
30:10
threat.
30:10
The
30:11
people
30:11
at
30:11
this
30:11
eulogy,
30:12
for
30:12
all
30:13
we
30:13
know,
30:13
they
30:13
are
30:13
not
30:13
going
30:14
to
30:14
chase
30:14
Carly
30:14
down
30:15
with
30:15
a
30:15
bunch
30:15
of
30:15
daggers
30:16
and
30:16
stone
30:17
her
30:17
to
30:17
death.
30:17
Even
30:18
if
30:18
she
30:19
had
30:19
a
30:19
panic
30:19
attack,
30:20
Even
30:20
if
30:20
she
30:21
collapsed
30:21
in
30:21
the
30:22
middle
30:22
of
30:22
the
30:22
eulogy
30:22
and
30:23
said,
30:23
I
30:23
can't
30:23
do
30:23
this,
30:23
I'm
30:23
too
30:24
nervous.
30:24
No
30:25
one
30:25
would
30:25
actually,
30:26
chances
30:26
are,
30:27
chase
30:27
her
30:27
with
30:28
pitchforks
30:29
and
30:29
call
30:29
the
30:29
New
30:29
York
30:30
Times.
30:30
Right?
30:31
But
30:31
that's
30:31
where
30:31
our
30:31
mind
30:32
goes.
30:32
Just
30:32
remember,
30:33
her
30:33
anxiety
30:33
or
30:34
fear
30:34
is
30:34
out
30:34
of
30:34
proportion.
30:35
This
30:35
usually
30:36
lasts
30:36
six
30:36
months
30:37
or
30:37
more
30:38
and
30:39
that's
30:39
also
30:40
part
30:40
of
30:40
the
30:40
diagnostic
30:41
criteria
30:41
and
30:41
it
30:42
causes
30:42
clinically
30:42
significant
30:43
distress.
30:43
Carly
30:44
is
30:44
clinically
30:45
significantly
30:46
distressed
30:47
and
30:47
she's
30:47
impaired
30:48
in
30:48
her
30:49
social
30:49
occupational
30:50
functioning.
30:50
Right?
30:50
She
30:51
can't
30:51
give
30:51
a
30:51
eulogy.
30:52
She
30:52
can't
30:52
pay
30:52
homage
30:53
to
30:53
the
30:54
guy
30:54
who
30:54
choked
30:54
on
30:55
peanut
30:55
brittle.
30:56
And.
30:56
And
30:56
that's
30:57
a
30:57
problem,
30:57
right?
30:58
That's
30:58
a
30:58
definite
30:58
issue.
30:59
It's
30:59
also
31:00
causing
31:00
her
31:00
in
31:01
her
31:01
career
31:01
as
31:02
a
31:02
librarian,
31:02
right?
31:03
She's
31:03
passed
31:03
down
31:04
actual
31:04
jobs
31:04
as
31:04
a
31:05
librarian
31:05
because
31:05
of
31:05
this
31:06
promotions.
31:07
So,
31:07
you
31:08
know,
31:08
that's
31:08
an
31:08
issue
31:08
too.
31:09
The
31:09
fear,
31:10
anxiety
31:10
or
31:10
avoidance
31:11
is
31:11
not
31:11
better
31:11
explained
31:12
by
31:12
symptoms
31:12
of
31:12
another
31:12
mental
31:13
disorder.
31:14
You
31:14
know,
31:14
you
31:14
want
31:14
to
31:15
rule
31:15
out
31:15
PTSD
31:16
here
31:16
too,
31:16
because
31:17
Gary
31:17
choked
31:18
on
31:18
the
31:18
peanut
31:18
brittle
31:18
right
31:19
in
31:19
front
31:19
of
31:19
her
31:19
and
31:19
she
31:19
did
31:19
not
31:20
tell
31:20
you
31:20
she's
31:20
having
31:20
nightmares
31:21
or
31:21
flashbacks
31:22
or
31:22
intrusive
31:23
thoughts
31:23
that
31:23
make
31:23
her
31:23
nervous
31:24
about
31:25
Gary
31:25
choking
31:25
on
31:26
peanut
31:26
brittle.
31:26
I'm
31:27
sorry,
31:27
Gary,
31:28
no
31:28
disrespect
31:29
to
31:29
you
31:29
whatsoever.
31:30
93%
31:31
of
31:31
people
31:32
don't
31:32
go
31:32
on
31:32
to
31:33
develop
31:33
PTSD
31:34
after
31:34
a
31:34
criterion,
31:34
a
31:35
trauma.
31:35
It
31:35
is
31:36
not
31:36
a
31:36
guarantee
31:37
that
31:37
just
31:37
because
31:38
you
31:38
are
31:38
exposed
31:38
to
31:38
A
31:39
traumatic
31:39
event
31:39
that
31:40
you
31:40
will
31:40
generate
31:40
PTSD
31:41
symptoms.
31:42
She
31:42
could
31:42
have
31:42
a
31:42
delayed
31:42
onset.
31:43
That
31:43
happens.
31:44
We
31:44
definitely
31:45
should
31:45
keep
31:45
that
31:45
in
31:45
mind.
31:46
Do
31:46
not
31:46
let
31:46
this
31:46
suspect
31:47
leave
31:47
the
31:47
police
31:47
station.
31:48
I
31:48
can
31:48
tell
31:48
you
31:48
that
31:48
right
31:48
now.
31:49
Don't
31:49
let
31:49
PTSD
31:50
suspect
31:51
leave
31:51
the
31:51
station
31:52
because
31:52
a
31:52
man
31:53
died
31:53
choking
31:54
on
31:54
Carly's
31:55
peanut
31:55
brittle.
31:55
Carly
31:56
baked
31:56
that
31:57
peanut
31:57
brittle.
31:58
She
31:58
didn't
31:58
even
31:58
ask
31:59
anybody
32:00
at
32:00
the
32:00
library
32:00
if
32:01
they
32:01
were
32:01
allergic
32:01
to
32:02
peanuts.
32:02
Talk
32:02
about
32:02
one
32:03
of
32:03
the
32:03
worst
32:03
things
32:03
to
32:04
bake,
32:04
by
32:04
the
32:04
way.
32:05
So
32:06
definitely
32:07
consider
32:07
PTSD
32:08
as
32:08
a
32:08
differential
32:09
here.
32:09
But
32:09
she
32:10
didn't
32:10
give
32:10
you
32:10
any
32:10
kind
32:11
of
32:11
criteria
32:11
that
32:11
would
32:12
suggest
32:12
that
32:13
there
32:13
is
32:13
a
32:13
specifier
32:14
for
32:15
social
32:15
anxiety
32:16
disorder
32:16
and
32:17
it
32:17
is
32:17
performance
32:17
only.
32:18
That
32:18
is
32:18
likely
32:18
what
32:18
we're
32:19
looking
32:19
at.
32:19
Social
32:19
anxiety
32:20
disorder,
32:21
specifier,
32:21
performance
32:22
only.
32:22
She
32:22
meets
32:23
all
32:23
the
32:23
criteria.
32:24
This
32:24
has
32:24
been
32:24
going
32:24
on
32:25
for
32:25
many
32:25
months,
32:25
since
32:26
she
32:26
was
32:26
a
32:26
young
32:26
kid.
32:27
Where
32:27
performance
32:28
situations
32:29
lead
32:29
to
32:29
significant
32:30
levels
32:31
of
32:31
avoidance,
32:31
impairment
32:32
and
32:32
distress.
32:33
But
32:33
again,
32:34
it's
32:34
probably
32:34
a
32:34
performance
32:35
only
32:35
specifier
32:36
because
32:36
Carly
32:37
does
32:37
not
32:37
exhibit
32:38
these
32:38
kind
32:38
of
32:38
anxieties
32:39
in
32:40
ordinary
32:40
social
32:41
situations.
32:42
A
32:42
couple
32:42
little
32:43
pearls
32:43
that
32:43
I
32:43
want
32:44
you
32:44
all
32:44
to
32:44
consider
32:45
for
32:45
social
32:45
anxiety
32:46
disorder.
32:47
Folks
32:47
with
32:48
social
32:48
anxiety
32:48
disorder
32:49
may
32:49
be
32:50
inadequately
32:50
assertive
32:51
or
32:51
excessively
32:52
submissive,
32:52
or
32:52
less
32:53
commonly,
32:53
highly
32:53
controlling
32:54
of
32:54
conversations.
32:55
They
32:56
may
32:56
show
32:56
overly
32:56
rigid
32:57
body
32:57
posture
32:58
or
32:58
inadequate
32:58
eye
32:59
contact.
32:59
They
33:00
may
33:00
be
33:00
shy
33:00
and
33:00
withdrawn.
33:01
There's
33:01
a
33:01
lot
33:01
of
33:01
overlap
33:02
with
33:02
avoidant
33:02
personality
33:03
disorder,
33:03
so
33:04
make
33:04
sure
33:05
you're
33:05
parsing
33:05
these
33:06
out
33:06
as
33:06
you
33:06
go.
33:07
72%
33:08
of
33:08
individuals
33:09
have
33:09
another
33:09
psychiatric
33:10
diagnoses
33:11
when
33:11
they
33:11
present
33:11
to
33:12
you.
33:12
With
33:12
social
33:12
anxiety
33:12
disorder,
33:13
you
33:13
definitely
33:13
want
33:14
to
33:14
rule
33:14
out
33:15
substance
33:15
use
33:15
disorders,
33:16
right?
33:16
Huge.
33:17
Huge.
33:17
Huge.
33:18
It
33:18
is
33:18
not
33:18
uncommon
33:19
for
33:19
people
33:19
to
33:20
medicate
33:20
with
33:21
alcohol
33:21
when
33:21
they
33:22
have
33:22
social
33:22
anxiety,
33:23
so
33:23
definitely
33:23
look
33:23
at
33:23
that.
33:24
You
33:24
also
33:24
want
33:25
to
33:25
look
33:25
at
33:25
any
33:25
other
33:25
potential
33:26
comorbidities.
33:26
We
33:27
ruled
33:27
them
33:27
out
33:27
already.
33:27
But
33:28
look
33:28
at
33:28
bipolar.
33:29
Look
33:29
at
33:29
adhd.
33:31
You
33:31
know,
33:31
look
33:31
at
33:31
body
33:32
dysmorphic
33:32
disorder,
33:33
right?
33:33
There's
33:34
so
33:34
many
33:34
potential
33:35
diagnoses
33:36
in
33:36
that
33:37
DSM
33:38
that
33:38
could
33:38
otherwise
33:39
explain
33:39
this
33:40
stuff.
33:40
But
33:40
you
33:40
definitely
33:41
get
33:41
a
33:41
huge
33:41
head
33:41
start
33:42
by
33:42
just
33:43
looking
33:43
at
33:43
the
33:43
chief
33:43
complaint
33:44
and
33:44
understanding
33:45
the
33:45
context
33:45
and
33:45
timing
33:46
of
33:46
this
33:46
stuff.
33:47
Now,
33:47
the
33:47
lifetime
33:47
prevalence
33:48
of
33:48
social
33:48
anxiety
33:49
disorders,
33:49
around
33:49
8
33:50
to
33:50
12%.
33:50
It's
33:51
one
33:51
of
33:51
the
33:51
more
33:51
common
33:51
anxiety
33:52
disorders.
33:52
And
33:52
the
33:52
age
33:53
of
33:53
onset
33:53
is
33:53
typically
33:54
between
33:54
8
33:54
and
33:55
15
33:55
years.
33:55
Most
33:56
people
33:56
have
33:56
a
33:56
childhood
33:57
history
33:57
of
33:57
social
33:57
inhibition
33:58
or
33:58
shyness.
33:59
Now,
34:01
that's
34:01
a
34:01
lot
34:01
to
34:02
kind
34:02
of
34:02
think
34:02
about.
34:04
And,
34:05
you
34:05
know,
34:05
this
34:05
stuff
34:06
can
34:06
manifest
34:06
after
34:06
humiliating
34:07
experience,
34:08
being
34:08
bullied,
34:09
maybe
34:09
vomiting
34:10
during
34:10
a
34:10
speech.
34:10
It
34:10
can
34:11
also
34:11
develop
34:11
kind
34:12
of
34:12
slowly.
34:13
Not
34:13
everybody
34:14
seeks
34:14
treatment
34:14
for
34:14
this.
34:15
And
34:15
it
34:15
is
34:15
highly
34:15
genetic.
34:16
First
34:16
degree.
34:16
Relatives
34:17
of
34:17
individuals
34:17
with
34:18
social
34:18
anxiety
34:18
disorder
34:19
have
34:19
a
34:19
2
34:19
to
34:19
6
34:20
times
34:20
higher
34:20
chance
34:21
of
34:21
having
34:21
social
34:21
anxiety
34:22
disorder
34:23
themselves.
34:24
And
34:24
I
34:24
hope
34:24
that
34:25
guides
34:25
you
34:25
in
34:25
your
34:26
path
34:26
as
34:26
you
34:27
confront
34:27
this.
34:28
Now
34:28
we're
34:28
going
34:29
to
34:29
talk
34:29
about
34:29
Pro
34:30
Perfect
34:30
Granalol.
34:31
It's
34:31
a
34:31
go
34:31
to
34:31
medication
34:32
for
34:33
social
34:33
anxiety
34:34
disorder
34:35
that
34:35
I
34:35
think
34:36
you
34:36
may
34:36
find
34:36
useful
34:37
in
34:37
your
34:37
practice
34:38
if
34:38
anxiety
34:39
is
34:39
circumscribed
34:41
to
34:41
performance
34:42
related
34:43
issues.
34:43
And
34:43
Carly
34:44
is
34:44
otherwise
34:44
totally
34:45
content
34:45
and
34:45
high
34:45
functioning
34:46
while
34:47
she
34:47
is
34:48
in
34:48
her
34:49
duties
34:49
as
34:49
a
34:49
librarian.
34:50
And
34:50
she's
34:51
just
34:51
looking
34:51
for
34:52
assistance
34:53
short
34:53
term
34:54
to
34:54
deliver
34:55
this
34:55
eulogy.
34:56
And
34:56
she
34:56
has
34:56
a
34:56
lot
34:56
of
34:56
somatic
34:57
symptoms.
34:57
I
34:57
think
34:57
probably
34:58
propranolol
34:59
is
34:59
a
34:59
very
34:59
good
35:00
option.
35:01
Welcome
35:01
to
35:01
this
35:01
part
35:02
of
35:02
the
35:02
show
35:03
called
35:03
Inside
35:03
the
35:04
capsule.
35:05
Propranolol.
35:06
10
35:06
years
35:06
of
35:06
mental
35:07
health.
35:07
I've
35:07
met
35:07
maybe
35:08
one
35:08
person
35:08
who
35:09
can
35:09
pronounce
35:09
this
35:10
and
35:10
that
35:11
person
35:11
is
35:11
not
35:11
me.
35:12
Okay,
35:12
so
35:13
propranolol
35:13
is
35:14
a
35:14
non
35:14
selective
35:14
beta
35:15
blocker.
35:15
It
35:16
puts
35:16
your
35:16
nervous
35:16
system
35:17
into
35:17
airplane
35:18
mode.
35:18
It
35:18
works
35:19
by
35:19
blocking
35:19
the
35:19
physical
35:20
effects
35:20
of
35:20
adrenaline,
35:21
epinephrine
35:22
and
35:22
norepinephrine.
35:23
And
35:23
it
35:24
that
35:24
kind
35:24
of
35:24
prevents
35:25
you
35:25
from
35:25
experiencing
35:26
that
35:26
racing
35:26
heart
35:27
tremors
35:27
or
35:27
sweating
35:28
that
35:28
often
35:28
accompany
35:29
performance
35:29
anxiety.
35:30
Essentially
35:30
mutes
35:31
the
35:31
body's
35:31
alarm
35:32
system,
35:32
allowing
35:33
the
35:33
mind
35:33
to
35:33
focus
35:34
without
35:34
the
35:34
overwhelming
35:35
physiological
35:36
signals
35:36
of
35:36
panic.
35:37
You
35:37
can
35:37
dose
35:38
it
35:38
between
35:38
10
35:38
and
35:38
40
35:39
milligrams,
35:39
30
35:40
to
35:40
60
35:40
minutes
35:40
before
35:41
it's
35:41
off
35:42
label.
35:42
And
35:43
best
35:43
for
35:44
discrete
35:44
anxiety
35:45
episodes
35:46
that
35:46
are
35:46
more
35:47
performative
35:47
and
35:47
somatic
35:48
in
35:48
your
35:48
body
35:49
type.
35:49
Anxiety.
35:50
That's
35:50
really
35:51
the
35:51
best
35:51
that
35:51
it's
35:52
used
35:52
for.
35:52
You
35:52
want
35:53
to
35:53
not
35:53
take
35:53
propranolol
35:54
if
35:54
you
35:54
have
35:55
a
35:55
history
35:55
of
35:55
asthma,
35:56
hypotension
35:57
or
35:57
bradycardia.
35:58
Those
35:58
are
35:58
some
35:58
contraindications
35:59
to
35:59
think
35:59
about
36:00
to
36:00
screen
36:01
your
36:01
patients
36:01
for.
36:02
We
36:02
have
36:02
way
36:03
more
36:03
information
36:03
about
36:04
propranolol
36:04
in
36:04
our
36:05
slide
36:05
deck
36:05
for
36:05
you
36:05
to
36:06
review.
36:06
Some
36:07
really
36:07
good
36:07
pearls.
36:08
Again,
36:09
urge
36:09
you
36:09
all
36:09
to
36:09
become
36:10
Patreon
36:10
members.
36:10
It's
36:11
well
36:11
worth
36:11
it.
36:12
Join
36:12
our
36:12
little
36:12
community.
36:13
Propranolol
36:14
is
36:14
really
36:14
good
36:14
for
36:15
wedding
36:15
vows,
36:15
pal,
36:16
public
36:16
speaking
36:16
recitals,
36:17
court
36:17
testimony,
36:18
exams.
36:19
It's
36:19
a
36:19
good
36:20
performative
36:21
medication.
36:22
Now
36:23
a
36:23
couple
36:23
little
36:24
pearls.
36:24
I
36:24
like
36:25
to
36:25
compare
36:26
propranolol
36:27
to
36:27
using
36:27
the
36:27
doorbell
36:28
analogy.
36:28
Okay,
36:29
now
36:29
if
36:29
you
36:29
imagine
36:30
adrenaline
36:31
as
36:31
a
36:31
frantic
36:31
party
36:32
guest
36:32
who
36:32
rings
36:33
doorbells
36:33
all
36:33
over
36:33
your
36:34
body.
36:34
Those
36:34
doorbells
36:35
are
36:35
beta1
36:36
and
36:36
beta2
36:37
adrenergic
36:38
receptors.
36:39
Propranolol
36:40
is
36:40
the
36:40
doorman
36:40
who
36:41
disconnects
36:41
the
36:41
doorbells
36:42
before
36:42
the
36:42
chaos
36:43
starts.
36:44
Right.
36:44
So
36:44
whenever
36:45
you're
36:45
stressed,
36:45
adrenaline
36:46
is
36:46
coursing
36:47
through
36:47
your
36:47
bloodstream.
36:48
Adrenaline
36:49
hits
36:49
these
36:49
receptors,
36:50
beta
36:50
1
36:50
and
36:50
beta
36:51
2,
36:52
and
36:52
it
36:52
wreaks
36:52
havoc
36:53
on
36:53
your
36:53
system.
36:53
It
36:53
makes
36:54
your
36:54
heart
36:54
rate
36:55
go
36:55
up,
36:56
makes
36:56
you
36:56
feel
36:57
sweaty
36:57
and
36:57
trembly.
36:58
Propranolol
36:59
is
36:59
cutting
37:00
a
37:00
wire
37:00
so
37:01
that
37:01
your
37:01
crazy
37:02
neighbor
37:02
or
37:02
party
37:03
guest
37:03
is
37:03
ringing
37:03
that
37:04
doorbell.
37:04
But
37:04
you
37:04
don't
37:05
have
37:05
the
37:06
physical
37:07
torment
37:08
of
37:08
feeling
37:08
it
37:09
or
37:09
hearing
37:09
the
37:09
doorbell.
37:10
He's
37:10
still
37:10
there.
37:10
He's
37:10
still
37:11
an
37:11
obnoxious
37:11
neighbor
37:12
that
37:12
you
37:12
wish
37:12
wasn't
37:13
your
37:13
neighbor.
37:14
But
37:14
the
37:14
doorbell
37:15
piece,
37:15
the
37:15
sounds,
37:16
is
37:17
not
37:17
bothering
37:17
you
37:18
as
37:18
much
37:19
because
37:19
propranolol
37:20
is
37:20
going
37:20
in
37:20
there,
37:20
and
37:20
it's
37:21
blocking
37:21
the
37:21
beta
37:21
1
37:22
and
37:22
beta
37:22
2
37:23
adrenergic
37:23
receptors.
37:25
And
37:26
so
37:26
the
37:26
physiological
37:27
response
37:28
is
37:28
kind
37:28
of
37:28
blunted.
37:29
And
37:29
that's
37:29
huge
37:29
for
37:30
a
37:30
lot
37:30
of
37:30
people
37:30
who
37:31
interpret
37:31
their
37:31
anxiety
37:32
in
37:32
physiological
37:33
ways.
37:33
Right?
37:33
They
37:34
are
37:34
disturbed
37:34
by
37:35
physiological
37:36
feeling
37:36
in
37:36
their
37:36
body,
37:37
and
37:37
it
37:38
promotes
37:38
this
37:38
cascade
37:39
of
37:39
really
37:40
frightening
37:40
cognitions.
37:41
And
37:41
then
37:41
pretty
37:42
soon,
37:42
you're
37:42
having
37:42
a
37:42
panic
37:43
attack
37:43
in
37:43
the
37:44
middle
37:44
of
37:44
your
37:44
eulogy.
37:45
So
37:45
I
37:45
like
37:45
that
37:45
analogy
37:46
because
37:46
beta
37:47
1
37:47
and
37:47
beta
37:48
2
37:48
receptors
37:49
are
37:49
on
37:49
the
37:49
heart,
37:50
the
37:50
muscles,
37:50
when
37:50
they're
37:51
being
37:51
stimulated
37:51
by
37:51
adrenaline.
37:52
That's
37:52
what
37:52
causes
37:53
the
37:53
tremor.
37:53
These
37:54
are
37:54
useful
37:54
symptoms
37:55
to
37:55
have.
37:55
If
37:55
you're
37:55
running
37:56
from
37:56
a
37:56
bear.
37:56
You
37:56
get
37:56
maximum
37:57
oxygen
37:58
delivery
37:58
by
37:58
taking
37:58
deep
37:59
breaths.
37:59
Your
37:59
muscles
38:00
are
38:00
ready
38:00
for
38:01
fight
38:01
or
38:01
flight.
38:01
To
38:01
run
38:02
away
38:02
from
38:02
the
38:02
bear.
38:03
Your
38:03
heart
38:03
is
38:03
racing
38:03
to
38:04
oxygenate
38:04
your
38:04
body
38:05
and
38:05
to
38:05
get
38:05
out
38:05
there
38:06
and
38:06
run
38:06
and
38:06
have
38:06
maximum
38:07
energy
38:07
to
38:07
run
38:08
from
38:08
the
38:08
bear.
38:08
It's
38:09
not
38:09
good
38:09
when
38:09
you
38:10
need
38:10
to
38:10
sit
38:10
still
38:11
and
38:11
not
38:11
look
38:11
like
38:12
you're
38:12
losing
38:12
your
38:12
mind.
38:13
When
38:13
you're
38:13
giving
38:13
a
38:14
eulogy
38:14
for
38:14
Gary,
38:15
remember
38:16
that
38:16
propranolol
38:17
sort
38:17
of
38:17
cuts
38:18
the
38:18
doorbell,
38:19
the
38:19
wire,
38:20
and
38:20
so
38:20
it
38:21
doesn't
38:21
stop
38:21
your
38:21
crazy
38:22
neighbor
38:22
from
38:23
ringing
38:23
it,
38:23
but
38:23
you
38:24
just
38:24
don't
38:24
hear
38:24
the
38:24
ringing
38:25
as
38:25
much.
38:25
You're
38:25
not
38:25
as
38:25
affected
38:26
by
38:26
it.
38:26
You
38:26
can
38:26
be
38:27
more
38:27
relaxed
38:27
because
38:27
there's
38:28
not
38:28
a
38:28
bunch
38:28
of
38:28
ringing
38:29
in
38:29
your
38:29
ear
38:29
every
38:30
minute.
38:30
That's
38:31
huge.
38:31
That's
38:31
a
38:31
big
38:32
deal.
38:32
The
38:32
key
38:33
takeaway,
38:33
the
38:33
key
38:33
pearl,
38:34
though,
38:34
is
38:34
that
38:35
it's
38:35
not
38:35
great
38:35
for
38:35
cognitive
38:36
worry.
38:36
That's
38:36
where
38:37
the
38:37
SSRIs
38:37
come
38:38
in,
38:38
right?
38:38
So
38:38
if
38:38
you
38:39
have
38:39
a
38:39
patient
38:39
who's
38:39
ruminating
38:40
and
38:40
worrying
38:41
and
38:41
a
38:41
lot
38:41
of
38:41
it's
38:41
cognitive
38:42
about
38:43
every
38:43
day,
38:43
all
38:43
day,
38:44
most
38:44
days.
38:44
General
38:45
worry
38:45
that
38:45
we
38:45
talked
38:46
about,
38:46
your
38:46
health,
38:46
your
38:46
finances,
38:47
that's
38:47
a
38:47
good
38:48
time
38:48
to
38:48
look
38:49
at
38:49
the
38:49
SSRIs,
38:50
right?
38:50
And
38:51
not
38:51
necessarily
38:51
propranolol
38:52
for
38:53
that.
38:53
Right?
38:53
So
38:54
just
38:54
think
38:54
about
38:54
that.
38:54
In
38:55
our
38:55
Patreon
38:57
Club
38:58
membership,
38:58
we
38:58
talk
38:58
a
38:59
lot
38:59
about
38:59
a
39:00
really
39:00
brilliant
39:01
psychological
39:01
theory
39:02
that
39:03
cuts
39:03
even
39:03
deeper
39:04
with
39:04
this
39:04
and
39:04
gives
39:04
us
39:05
even
39:05
more
39:05
reason
39:05
why
39:05
propranolol
39:06
makes
39:06
so
39:07
much
39:07
sense
39:07
in
39:07
cutting
39:08
off
39:08
the
39:08
somatic
39:09
feedback
39:10
cycles
39:10
that
39:10
worsen
39:12
anxiety
39:12
and
39:12
cause
39:13
more
39:13
distress.
39:14
James
39:14
Lange
39:15
theory.
39:15
We're
39:15
going
39:15
to
39:15
go
39:15
over
39:16
that
39:16
more
39:16
in
39:16
our
39:16
Patreon
39:17
page
39:18
in
39:18
our
39:18
bonus
39:18
slide
39:19
deck.
39:19
So
39:19
definitely
39:20
check
39:20
that
39:20
out
39:20
if
39:21
you
39:21
can.
39:21
I
39:22
would
39:22
like
39:22
to
39:22
bring
39:22
this
39:23
case
39:23
to
39:23
a
39:23
close,
39:23
my
39:24
friends
39:24
and
39:24
I
39:24
hope
39:24
you
39:24
had
39:25
fun
39:25
with
39:25
it.
39:25
I'm
39:25
so
39:25
sorry
39:26
for
39:26
what
39:26
happened
39:26
to
39:26
Gary.
39:27
Carly
39:28
is
39:28
not
39:28
really
39:29
any
39:29
picnic
39:29
for
39:29
her
39:29
either.
39:30
She's
39:30
a
39:30
victim
39:31
in
39:31
all
39:31
this
39:31
too.
39:32
At
39:32
the
39:32
end
39:32
of
39:32
the
39:32
day,
39:32
this
39:33
is
39:33
likely
39:33
social
39:33
anxiety
39:34
disorder
39:35
performance
39:35
only.
39:36
F40
39:37
10.
39:38
Carly
39:39
was
39:39
prescribed
39:40
propranolol.
39:40
She
39:41
tolerated
39:41
it
39:41
well.
39:42
She
39:42
took
39:42
it
39:42
about
39:42
30
39:43
to
39:43
60
39:43
minutes
39:44
prior
39:44
to
39:44
the
39:44
eulogy
39:45
that
39:45
she
39:45
gave.
39:45
And
39:45
she
39:45
gave
39:46
a
39:46
beautiful
39:47
eulogy.
39:47
Everybody
39:48
cried
39:49
except
39:49
for
39:50
Carly.
39:50
Not
39:51
because
39:51
she
39:51
wasn't
39:51
sad,
39:52
but
39:52
because
39:53
she
39:53
was
39:53
throwing
39:54
focused
39:54
on
39:54
her
39:54
speech
39:55
and
39:55
was
39:55
a
39:55
nervous
39:55
wreck
39:56
the
39:56
whole
39:56
time.
39:56
She
39:57
didn't
39:57
feel
39:57
it
39:57
in
39:57
her
39:58
body,
39:58
which
39:58
is
39:58
a
39:58
win.
39:59
Right?
39:59
She
39:59
didn't.
39:59
The
39:59
heart
40:00
wasn't
40:00
racing
40:00
so
40:00
fast.
40:01
She
40:01
wasn't
40:02
trembling
40:02
when
40:03
she
40:03
was
40:03
holding
40:04
the
40:04
Microsoft
40:05
Word
40:05
document.
40:05
She.
40:06
She
40:06
gave
40:06
a
40:06
pretty
40:06
darn
40:07
good
40:07
eulogy.
40:08
We
40:08
do
40:08
recommend
40:09
that
40:09
Carly
40:09
maybe
40:10
goes
40:10
to
40:10
therapy.
40:11
She
40:11
psychotherapy.
40:12
She
40:12
does
40:12
have
40:13
a
40:13
history
40:13
of
40:13
neglect.
40:14
Maybe
40:14
she
40:14
could
40:15
look
40:15
into
40:15
that
40:15
more
40:16
closely
40:16
or
40:16
into
40:17
any
40:17
dynamics
40:17
that
40:18
might
40:18
have
40:18
shaped
40:18
her
40:18
life
40:19
over
40:19
the
40:19
years
40:19
that
40:19
would
40:20
make
40:20
her
40:20
nervous
40:21
in
40:21
front
40:21
of
40:21
other
40:21
people.
40:21
That
40:22
is
40:22
perfectly
40:22
appropriate
40:23
to
40:23
do
40:23
something
40:23
like
40:24
that.
40:25
She
40:25
meets
40:26
criteria
40:26
for
40:26
social
40:26
anxiety
40:27
disorder.
40:27
If
40:28
you're
40:28
a
40:28
new
40:28
grad
40:28
or
40:29
you're
40:29
a
40:29
nurse,
40:29
NP
40:30
student.
40:31
Remember
40:32
that
40:32
your
40:32
job
40:32
in
40:33
that
40:33
first
40:33
60
40:33
minutes.
40:34
You're
40:34
not.
40:34
You're
40:34
not
40:35
Superman.
40:35
Okay?
40:35
You're
40:36
not.
40:36
You're
40:37
not
40:37
expected
40:37
to
40:39
nail
40:39
a
40:39
DSM
40:40
5
40:40
diagnosis
40:41
with
40:41
absolute
40:42
precision.
40:43
It
40:43
would
40:43
be
40:44
great
40:44
if
40:44
you
40:44
could.
40:44
You
40:45
should
40:45
always
40:45
shoot
40:45
for
40:45
the
40:45
stars.
40:46
But
40:46
at
40:46
the
40:46
same
40:46
time,
40:47
you
40:47
want
40:48
to
40:48
just
40:48
line
40:48
up
40:49
your
40:49
suspects.
40:50
Get
40:50
the
40:50
ones
40:51
in
40:51
handcuffs
40:52
that
40:52
probably
40:53
need
40:53
to
40:53
be
40:53
in
40:53
handcuffs
40:54
and
40:54
keep
40:54
some
40:55
at
40:55
the
40:55
police
40:55
station.
40:56
Always
40:56
monitor
40:57
labs
40:57
to
40:58
make
40:58
sure
40:58
nothing's
40:58
worsening
40:59
this.
40:59
Monitor
41:00
her
41:00
use
41:00
of
41:00
death
41:01
wish
41:01
coffee.
41:02
Keep
41:02
differentials
41:03
in
41:03
your
41:03
mind.
41:03
But
41:03
again,
41:04
the
41:04
goal
41:04
here
41:04
is
41:05
at
41:05
the
41:05
end
41:05
of
41:05
the
41:06
day,
41:06
you
41:06
have
41:06
a
41:06
patient
41:06
who's
41:07
suffering,
41:07
who
41:07
needs
41:07
some
41:08
relief.
41:08
And
41:09
we
41:09
have
41:09
a
41:09
broad
41:09
list
41:10
of
41:10
tools
41:11
and
41:11
questions
41:12
to
41:12
ask
41:12
to
41:12
get
41:12
her
41:13
that
41:13
relief
41:13
in
41:13
that
41:14
60
41:14
minutes.
41:14
And
41:14
if
41:14
you
41:15
can
41:15
do
41:15
that,
41:15
you
41:15
are
41:16
a
41:16
hero
41:16
enough
41:17
in
41:17
the
41:17
eyes
41:18
of
41:18
everyone
41:18
else
41:19
and
41:19
yourself.
41:20
So
41:20
just
41:20
take
41:20
that
41:21
burden
41:21
off
41:21
a
41:21
little
41:22
bit
41:22
and
41:22
do
41:22
your
41:22
darn
41:23
best.
41:23
You
41:24
don't
41:24
want
41:24
to
41:24
be
41:24
wildly
41:25
out
41:25
of
41:26
whack
41:26
here
41:26
and
41:27
diagnose
41:27
her
41:27
with
41:27
a
41:27
spider
41:28
phobia
41:28
when
41:29
she
41:29
clearly
41:29
didn't
41:29
talk
41:30
about
41:30
spiders
41:30
even
41:30
once
41:31
in
41:31
that
41:31
60
41:31
minutes.
41:33
You
41:33
want
41:33
to
41:34
get
41:34
kind
41:34
of
41:34
close
41:34
to
41:34
the
41:34
diagnosis.
41:35
And
41:36
you
41:36
know,
41:37
in
41:37
this
41:37
case
41:37
it
41:38
was
41:38
pretty
41:38
clear
41:39
off
41:39
the
41:39
bat
41:39
where
41:39
you
41:40
could
41:40
at
41:40
least
41:40
zero
41:40
in
41:41
on
41:41
now.
41:43
I
41:43
hope
41:43
you
41:44
enjoyed
41:44
this.
41:45
We
41:45
have
41:45
a
41:46
Power
41:46
Pearls
41:47
recap
41:47
here
41:47
before
41:48
we
41:48
say
41:48
goodbye.
41:49
The
41:49
key
41:49
here
41:50
is
41:51
to
41:51
diagnose
41:52
the
41:52
loop,
41:52
not
41:52
just
41:52
the
41:53
label.
41:53
If
41:53
anxiety
41:54
hits
41:54
only
41:54
before
41:54
speeches
41:55
or
41:55
interviews
41:55
and
41:56
not
41:56
in
41:56
daily
41:56
life,
41:56
think
41:57
performance
41:57
only
41:57
social
41:58
anxiety,
41:58
not
41:59
gad.
41:59
Skip
42:00
the
42:00
chronic
42:00
meds.
42:01
If
42:01
that's
42:02
the
42:02
case.
42:02
Treat
42:02
situationally
42:03
with
42:03
propranolol.
42:04
By
42:05
all
42:05
means.
42:05
Please
42:05
do
42:05
not
42:06
go
42:06
straight
42:06
to
42:06
like
42:07
a
42:07
high
42:07
dose
42:08
of
42:08
Klonopin
42:08
and
42:09
everyone's
42:09
going
42:09
to
42:09
look
42:09
at
42:09
you
42:09
weird.
42:10
Try
42:11
to
42:11
start
42:11
with
42:11
the
42:12
propranolols.
42:12
If
42:13
this
42:13
is
42:13
somatic
42:13
anxiety
42:14
and
42:16
you
42:16
know
42:16
the
42:17
patient
42:17
kind
42:17
of
42:18
looks
42:18
and
42:18
feels
42:19
like
42:19
Carly
42:19
here,
42:20
you
42:20
definitely
42:20
want
42:21
to
42:21
start
42:21
at
42:21
a
42:21
low
42:22
dose,
42:22
but
42:22
it
42:22
could
42:22
have
42:22
a
42:23
very
42:23
big
42:23
impact.
42:24
Start
42:24
at
42:24
10
42:25
milligrams,
42:25
especially
42:26
for
42:26
small
42:26
athletic
42:27
or
42:27
bradycardic
42:27
patients.
42:28
You
42:28
want
42:29
to
42:29
avoid
42:29
sedation
42:29
or
42:30
brain
42:30
fog.
42:30
Don't
42:30
block
42:31
the
42:31
wrong
42:31
airways,
42:32
folks.
42:32
Propranolol,
42:33
that
42:33
little
42:34
doorbell
42:34
analogy
42:35
I
42:35
gave
42:35
you,
42:35
Remember,
42:35
it
42:36
does
42:36
block
42:37
the
42:38
neighbor
42:38
ringing
42:39
the
42:39
doorbell
42:39
on
42:39
the
42:39
lungs.
42:40
If
42:40
you
42:40
have
42:41
asthma
42:41
or
42:41
copd,
42:42
that's
42:42
a
42:42
problem
42:43
because
42:43
you're
42:44
going
42:44
to
42:44
close
42:44
up
42:44
the
42:44
airways
42:45
and
42:45
that's
42:45
going
42:46
to
42:46
make
42:46
breathing
42:46
a
42:46
little
42:46
more
42:47
difficult.
42:47
So
42:47
I
42:48
hope
42:48
you
42:48
enjoyed
42:48
these
42:49
Pearls.
42:49
Remember,
42:49
ask
42:50
great
42:50
questions,
42:52
do
42:52
the
42:52
best
42:52
you
42:53
can,
42:53
and
42:54
I
42:54
would
42:54
love
42:55
if
42:55
all
42:55
of
42:55
you
42:56
would
42:57
email
42:57
me
42:57
your
42:58
thoughts.
42:59
That's
42:59
it
42:59
for
43:00
today's
43:00
case.
43:00
If
43:00
you
43:00
want
43:01
to
43:01
go
43:01
deeper,
43:01
check
43:01
out
43:01
my
43:02
Patreon
43:02
link
43:02
in
43:03
the
43:03
Show
43:03
Notes
43:03
where
43:03
you
43:03
can
43:04
join
43:04
Case
43:04
Close
43:05
our
43:05
exclusive
43:06
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43:06
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43:06
private
43:07
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43:07
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43:08
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43:08
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43:08
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43:08
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43:08
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43:09
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43:09
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43:11
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43:11
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43:12
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43:12
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43:13
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43:13
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43:13
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43:14
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43:14
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43:15
Or
43:15
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43:15
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43:15
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43:16
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43:16
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43:16
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43:16
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43:17
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43:17
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43:18
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43:18
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43:20
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43:20
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43:21
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43:21
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43:22
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43:22
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43:22
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43:22
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43:23
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43:23
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43:24
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43:24
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43:24
psychopharmacology
43:25
and
43:26
more.
43:26
Support
43:27
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43:27
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43:27
Leave
43:28
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43:28
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43:28
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43:28
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43:29
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43:29
That
43:29
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43:29
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43:29
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43:30
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43:30
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43:30
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43:30
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43:30
If
43:31
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43:31
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43:31
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43:32
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43:32
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43:32
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43:33
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43:33
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43:33
Podcasts
43:34
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43:34
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43:34
keep
43:35
learning
43:35
my
43:35
friends.
43:36
I'll
43:36
catch
43:36
you
43:36
next
43:36
time
43:37
right
43:37
here
43:37
on
43:38
Pearls
43:38
and
43:39
Prep.
43:39
Thank
43:39
you.